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FUR OFFICE USE: FOR OFFICE USE: !+ <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- - --- <br /> (Complete in Triplicate) Permit No,/------ <br /> o. .. .._l/ <br /> ' •- v�'��`�9 <br /> .................. •------- ------ ------------- Date Issued. <br /> ----- This Permit Expires 1 Year From Date Issued i <br /> i <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 compliarice with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO ------------------- ------..CENSUS TRACT........... .. --. <br /> iOwner's Name............... 5 -.- ---- .............. n y Phone. :..�~, _. _�....... <br /> Address.................. <br /> Contractor's Name / <br /> License o�.....Phone- W,_�s_ A. 111.x.... <br /> fInstallation will serve: Residence Apartment House F] Commercial [❑ Trailer Court ❑ <br /> Motel ❑ Other--.- - --------------------------------- <br /> Number of living units:..._../. ......Number of bedrooms-...c�?—.Garbage Grinder-------......Lot Size__. l- d <br /> Water Supply: Public System and name.. ........... c.L f�(� ------ ----------............................. ---------------7------Private ❑ <br /> k 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 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 <br /> permitted if public sewer is available within 204 feet,) � W <br /> rPACKAGE TREATMENT ( } SEPTIC TANK ( Size........yo�..,ef I--------------- --- - .--.-.Liquid Depth...-.---------------- <br /> Capacity..1 Z4P4-___..TYp /t?� ..M -------:No. Compartments ----.:r --------------- <br /> Distance <br /> ---------- -- - <br /> t Barest: 1NeIL...--- - ------ -----------Foundation..-.lel. - -. --.Prop. Line.._._. ....... <br /> ('� No. of Lines <br /> istance to n <br /> g -�d-G------------- Total Length Z P-0----........ <br /> - ------ <br /> LEACHING LINE , __. ~..... ....:........Len Length of line... <br /> D' Sox-.---..--:..Type Filter Material.S�YC Depth Filter Material.._. . ......................... .--__.-- _°-,-.--_--- <br /> Distance,to nearest: Well---... .._-. _� . __ "....Foundation.___. S-r_..-...._ _Property Line---------------------- ........._ , <br /> SEEPAGE PIT [ Depth...!�S _'.._Diameter... <br /> 31A........ Number--------------------_----_------- Rock Filled Ye� No ❑ <br /> Water Table Depth - .......... -----------------Rock Size......,P.?.0 ------------ ----• <br /> Distance to nearest: Well...-.-__ ............._.Foundation.---.,��..... -- Prop. Line..���..---....--.-._-.... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----------------------------I....... .................Date-.-.,.- ........................... <br /> Septic Tank (Specify Requirements) L�`.... ------------- ----------- --------- - ---- ------------= ------------------------ ----------- ..........--I--------.. <br /> Disposal Field (Specify Requirements)t ---- ---- ----------- ----- ------------------- ----....---... -- ------ <br /> P A Y q <br /> ---------------_ ----------------------------- -- ------ ---------------------------------------- ........ -------------------------------------------------------- ---•-------- -------- ------------ <br /> --------------------- -------------•------ -------------------------------------- --...------------•------- ----.._....-----.--.---------....-----...-----.-- ---....._..-------- <br /> i _. (Draw existing and required addition on reverse side) it <br /> I hereby certify that I have ptepared,thls 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 shall not employ any person in such mariner as <br /> to become subject to�Wman'sCation lawsof California." <br /> ..._.. � - �we•r <br /> ,y <br /> ------- ... ...........Title---------...--- ------------ -- <br /> - -- -- --- -- -- <br /> {If other than owner] <br /> fQ4 DEPARN USE ONLY la, <br /> APPLICATION ACCEPTED BY.---- -- kyr'-`---'--- ---_ _' ..1�C !' ---------------------------.....DATE.-----._ ._.��.4..--_--- _...i..---- - <br /> �t=�r r'c. Vr <br /> DIVISION OF LAND NUMBER.-- __ DATE----------- ------------- ------------------ <br /> ADDITIONAL COMMENTS ------------------- -------- ....---...--. <br /> ----•.-------- ---- - ---- -•--- ----- -----:----------- -------- --- --------------------.... <br /> ect <br /> Final Inspion by:------------------ - - ------------------- .:..__._Date.------- . <br /> 1 1 <br /> E" 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&W1677 REV.'7/76 3M <br />