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FOR OFFICE USE: <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT q <br /> ------------------------------ - - Permit No.71���—��-/- <br /> ----------------- <br /> (Complete in Triplicate) <br /> -------------- ' <br /> Date Issued___�'�_-_�� <br /> --------------------------------------------------------- This Permit Expires 1 Year From Datelssued <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---� �� <br /> -- -:9z -4--------------- u7_1W t� �------- --------------------CENSUS TRACT - <br /> Owner's Name--- A.`------/_ x . ----- - - ----- -- --- -- ---- -- - ---- -- ----Phone -- �--- --- <br /> s q <br /> Address- -- - ----- �.. - �__'- =-_ '�.._ - <br /> ---------------------------------------City�%�-?U7C 7 - ------ZiP` <br /> Contractor's Name � t � t - License #_ i 'at Phone------------------------------ <br /> ---------------------Installation will serve: Residence❑ Apartment House.F Commercial ❑ Trailer Court ❑ <br /> _ ..Motel-❑ Other-------- c <br /> Number of living units:... ----------Number of bedrooms__- Garbage Grinder------------Lot Size__ -------------------------------- <br /> Water <br /> Ty' -------- --- ---- ---------- <br /> WaterSupply: Public System and name------------------ ---------------------------------------`;.---------------------------------- ----------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ;K , Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material_-.-------If yes,type________________________ .� <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ I Size--------------------------------------------------- --==--Liquid Depth.______-__-_______------ <br /> Capacity---------------------Type-----------------------Material--------------------------No. Comp&rtments--------- --------- --------------- <br /> Distance to nearest: Well_----------------------------------------- Foundation-----------------'-------Prop. Line---------------------------- <br /> LEACHING LINE ( l No. of Lines-----------------------------Length of each line.------------------------------ -Len gth.___--____________------.------------ <br /> 'D' Box__________Type Filter Material--------------------Depth Filter Material-----------;-------.-------------------------------------------- <br /> Distance to nearest: Well----------------------------Foundation---------------- -----------Property Line_--------------- ----------------- <br /> SEEPAGE PIT ( ] Depth- .-_._.------Diameter---------.----------Number-------------------------------- Rock Filled Yes ❑ fib[' <br /> Water Table Depth---------------- - :---=------Rock Size---------------------'------------------------- <br /> Distance to nearest: Well ----------------------------------- Foundation----------'--- - :---Prop. Line------------------------ -- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-. __--- ----------- - Aate---------- -- --------------------- <br /> Septic <br /> ---_. -----Septic Tank (Specify Requirements)----- _ :--- --°---- ------ --x --- <br /> ------ ---- ---- <br /> Disposal Field'A§pecify Requirements�j..-_� � <br /> a __ _— <br /> A <br /> =� =--- ------=--------------------- - ----------------------------- ---- --------------- ----------- ------------------------- <br /> ---------------------------- -=� -- -_ - ----- ------------------------------------------------------------------------------------------ ----------------------- <br /> - (Draw existing and required addition on reverse side) <br /> I hereby certify that I have rprepared_this application,.and..thaLthe-_,work_will-.-be. done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the 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 which this permit is issued, I shall not employ any person in such manner as <br /> to becomesub'ect t 'kman' ompensation laws of California." <br /> g <br /> ned . <br /> Si -----------------Title __ -. --�--- -------- ------..Owner <br /> Z ~ . ----- ---- , <br /> T_ -------- -------------------------- <br /> (If other than owner) <br /> FO DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY----------- - -- --- - -- --- -- --------- ----------------------------------------------------------DATE.. ------ -------- --------------- <br /> DIVISIONOf LAND NUMBER- ------- ---- -_- _- ---- - - -- - --.- ----------------- __ DATE-------------------------------------- ------------ <br /> ADDITIONAL COMMENTS----- ---- ------- '-------- -------- - ------ -------- --------- ----------- <br /> ------------------------ <br /> -------------------------------------------------- ------------------------------------------ - <br /> -- - --- / <br /> __-..______Date___..-____-._ 3C <br /> Final Inspection b <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICTF&s 21677 REV. 7/76 3M <br />