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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....... .. . -------• (Complete in Triplicate) Permit No..?7" <br /> .......•q:G✓.. <br /> ..................•- • ------. ------ -----• --- <br /> -- q Date Issued..--�-�..:' <br /> ......................!-.1/..l1 --- -------- -. -... 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 existi11 ng Rules and Regulations: <br /> JOB ADDRESS/LOCATION----a-3 .t}'" 56, �U 5/�N ------ --------------•-•------•-----------..CENSUS TRACT-------------------------------- <br /> Owner's Name.._ ....fl�' Y. - .. /-�a�f 4`77 /9d� <br /> Phone - ----------------- -- --...... <br /> Address " W,-)>1 city T <br /> -----• ---­----- -----Zip......... ------ --------- <br /> ----- ----- . .............. - ----- ------- <br /> Contractor's Name---------' Tho..--Y,.-._..t.-_sow ,1 C,6-S9'G _ 523-y-zJ'1 <br /> - License # Phone- <br /> Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------ ------- ------------------------ <br /> �6 fx res <br /> Number of living units:.._- .......Number of bedrooms_.:3.__-;. Garbage Grinder----.-......Lot Size_--.--....-..-._ <br /> Water Supply: Public System and name_. ----- Private <br /> Character of soil to a depth of 3 feet: Sand,] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material . -..-__ If yes, type--_-----------__---- <br /> (Plot <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 [ ] Size ------- ...__-------------------------------------------Liquid Depth :._-.__._--------- .--pQ <br /> Capacity .1800 .-.-Type--p r.-.Material.---G ons c ---.:No. Compartments------W---•----- --------- -----'S <br /> Distance to nearest: Well..........'.P---. -----. -. .Foundation....�.Q.`. _.-.. __..Prop. Line----- ---------.--.IN, <br /> LEACHING LINE [ ] No. of Lines _....................Length of each line..--_--.---_--_-----..._.Total Length ..--...-A <br /> D' Box._-I... ..T a Filter Material__4a� ... Depth Filter Material__ `i'.-........................ � <br /> H:< Tyr ljes/ ...Type - - p --- -------- -------- <br /> Distance to nearest: Well --. --.-_._-..----. Foundation---------------------------Property Line....-------------_---.----.------. <br /> SEEPAGE PIT [ ] Depth.-- Diameter.....-------------.-.Number-...--.----.-------_-_------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth----- •--- . --••--....Rock Size-- . --- ....... --------------------•-_--- <br /> Distance to nearest: Well----------- --- -------- ..................Foundation... ------------... ......Prop. Line----- ---------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------- .--- ---............Date.....---------------- ------------------ ---) <br /> Septic Tank (Specify Requirements)------ -- ---------------------_-- •---•- <br /> Disposal Field (Specify Requirements). . . ------• - .......... -------- •----------•- <br /> ---- ....... ----------------- ----- --------- ----------------- ......... <br /> ............. -------------- -------- -------- -- . -- - -----••--- ---- -------------- ------------••----------------- -- -------- -_......... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the 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 shalt not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> el <br /> Signed------ ----'e-- - --------- ----•----- -----..Owner <br /> By...--- .......... --`-/ ---- --------------.........------ -- - Title <br /> (Ia er than owner) <br /> FOR DEPARTMENT USE ONLY 2 <br /> APPLICATION ACCEPTED BY---------- - - -.- ..__DATE -...,.--- ------2-.7-" j(------=- <br /> DIVISION OF LAND NUMBER------------- -•------- ----------------.DATE...... ------• -....... - ---- <br /> ADDITIONAL COMMENTS----_-_----------- ---- - <br /> --------...__----- -----------.........-_--..._....:._..-------------•---- - -- --- -----•--.----- ...... ------- -------•--- <br /> ----------------------------- ------- ---------- ._...---------- --- ..................... ....... -..--------•--•--- <br /> ...----•--••-----•--------- -------- - ---- - - - --- -- ------- ------------- ----- <br /> Final Inspection b _...•.....-._Date_.--.�f- :3- . .. ....--- ..... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M <br />