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FOR OFFICE USE:. ✓ APPLICATION FOR SANITATION PERMIT FOR OFFICE USES <br /> ----"---- --- ------- ------ `y- - - - -----•-- Permit No.?f--/".. <br /> (Complete in Triplicate) <br /> .................._. <br /> Date Issued-fl.•-�:�=. <br /> ...... ........".. .. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION........ : tiT�L-- -- /aS ......4 L_J���F---"------- •------------- ------.CENSUS TRACT..........._------------------ <br /> I <br /> _ --_----------."--- <br /> Owner's Name..-- 1 "C �.. . .,j. ..............Q--- ---- ------ <br /> 's 1. J... Phone -�i.Z"_.5 .1.�.. <br /> Address--------------- _.... .----.7T.._ .�7 I�-� -`City--_57v'Cr l`+ -._....... Zip--•------- ------ <br /> Contractor's Name--- ---- 1--k-_----40.0.e-- " .-----------...License #"._ G !fit Phone--.-. ,�-.:nils ."' tg. <br /> Installation will serve: Residence ❑ Apartment House Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- --- --- ---------.------- ------ <br /> Number of living units:----- // Number of bedrooms."_..I......Garb ge Grinder___.-.._--_-Lot Size__ 0.--X - 6 --- - <br /> Water Supply: Public System and name.-_-------01. :'-....---�.SJ -"..-. .------. .........Private ❑ <br /> -- ---- - - --------"--- ----• •--------..__..-- <br /> Character of soil to a depth of 3 fe4t:' Sand ❑ Silt[IClay ❑ Peat [_1Sandy Loam ElClay Loam ❑ <br /> Hardpan [n Adobe ❑ Fill Material__"-. __If yes, type-•-• ".*• A+j 3e"_ 6e-lotto 40.40 t� <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) N <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) &J <br /> PACKAGE TREATMENT,,[ ] SEPTIC TANK [ ] Size -...--_-".-..._-_-"_-_-_-__-_---__-- Liquid Depth...-_".-._..-.-"---..-_-- <br /> Capacity---- --...... ------Type-------- ------ -----Material----------".. ...........No. Compartments-.......-•...................... <br /> Distance to nearest: Well-:"---------" Foundation-...__ ._ -. -.-.-. .".Prop. Line----- ---------_------ - <br /> LEACHING LINE [ ] `No. of Lines ........."..................Length of each line......................... ....Total Length _ ------------- ---- <br /> 'D' Box...-..---_Type Filter Materi�l,.."-----------------Depth Filter Material........•.............................. ........ -----------" <br /> Distance to nearest: Well...............f:`---.........Foundation-------------------------_Property Line--------- ----------------------- <br /> Rock Filled Yes . <br /> SEEPAGE PIT ( ] Depth----- Diameter--.___f;t.-_y_r.,--Number_..-_"_________________________ ❑ No <br /> Water Table Depth.... . . :Rock Size—------------- <br /> Distance to neae' t Well_."_----_- ------- -°;:. ', ..Foundation.---- ---- - ------------Prop. Line-- - -- ....... <br /> EPAIR/ADDITIO (Prev. Sanitation Per --. - - --- - <br /> - Date...................... - _---- -- ___ <br /> ) <br /> Sep 1 Specify Requirements)-- ' P"-- --1 ------ <br /> .14 <br /> - 1 <br /> Disposal Field (Specify Requirements)_:- � �,� """""' <br /> ..__._. ... -- - ----- <br /> (Dr n!,,qxisting and required addition on reverse side) <br /> 1 hereby certify that I have prepared this.�appliicatlda an9k halthework will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules an .deg"ur <br /> dns al �%6,San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for whichis permit is issued, I shall. not employ any,person in such manner as <br /> to become subject to Workman's Compensation laws of-California." <br /> Signed --- ------------ .........- -•- .._... ."-- - ---- -/ nor <br /> __ ---- -- .-.'title--_5'C1.M....!y _ <br /> (If other an owner) Q�6" G��" �► <br /> 1(r EPAR ENT USE ONLY <br /> ACCEPTED BY----------- <br /> ' ----- -DATE ------ <br /> APPLICATION <br /> DIVISION OF LAND NUMBER-------- ------ --------- ----------.--_-_ -------------------- <br /> --------------------"----•---------.DATE.------------•--•-- --- --.. ---------------- <br /> DIVISION <br /> - ...---- -- - <br /> ADDITIONAL COMMENTS-------------------- ------ ------ <br /> ----------------"------- - -"-- - ----- ----------"- ....-- . ....... <br /> ..................................-." .------- -------- ...................... ..................... <br /> /l <br /> . <br /> . ------------------------------------------------ � .------------------------ .. ..... <br /> - <br /> Date <br /> ' `Final Inspection by: <br /> EH 13 24 V SAN JO QUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />