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FOR OFFICE USE: - 'FOR OFFFCE­USE: � I <br /> fi <br /> (Complete in Triplicate) <br /> " APPLICATION FOR SANITATION PERMIT <br /> Ppermit No. <br /> (Comg <br /> -•-•------ ........ <br /> Date Issued.�J= �: <br /> .................. ---------- This Permit Expires .1 Year From Date Issued <br /> i ' <br /> i.. <br /> Application is hereby made to-the San .loaquin 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......_I�. ..�..E. I LT1E 4 4 / G ..........CENSUS TRACT-_.............. <br /> 36?—S.5'2 <br /> Owner's Name / (/ -'. _,$ �S' /i2r...... .........:..... ............ --.--............ <br /> Phone..... ------•------- <br /> Address_ ----------- - ---................City------- - - zip--- - -..... -------. <br /> Contractor's Name---.Pa/5 .-- Sv.�Js.-.-__.-__-•---- se Phone--- <br /> ... .................... .Licen <br /> T <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> p 0W97, �E h6 t� <br /> Motel ❑ Other- --.......�- ---------------------- <br /> Number <br /> --------------- -Number of living units:...... ..._..._Number of bedrooms.3....._Garbage Grinder............Lot Size,-........ - ------- '-..-. - -- <br /> Water Supply: Public System and namefl......: - - Private <br /> Character of soil to a depth of 3 feet; Sand ❑ Silt❑ Clay ❑ Peati[] Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ' AdobeX Fill Material.. -........Ifyes 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 Size ...... �r--x�- ------------------ ------Liquid Depth.._S _..--.".: --- <br /> I DD T e__ G---------_No. Compartments_........a-.---I------- <br /> Capacity <br /> -�-�--- ...... -- YP --- =�-:_Founda#�on -� _ .. p. ''_....... <br /> e to <br /> I_en th of each line...-... --------------Total Length -__.l. <br /> LEACHING LINE No. ofare 'Well__;...--.. �.._. Pro Line2O- .0 <br /> �Q g <br /> D' Boxy - Type„Filfer Nlafierial_,:ROGk Depth Filter Material.~:='-�... <br /> 8 ' <br /> i ndati n-- <br /> /OEJ , ...�--- .Fou o .�0��' Pro ert L.: �- -,-�.��/ -- <br /> Distance to nearest: Well p Y inea...” <br /> SEEPAGE PIT ] �Depth_af.......Diameter. -33 ..---.Number-...-- ............ r Rock Filled Yes �No <br /> 3r ir., <br /> Water Table Depth...-------------------------- .- Rock Size..... �i X I h --- - <br /> Distance to nearest: Well.----------- ..... ..:...........Foundation.;:_. -.�_�-.-.-.PropLine.. . -..- --"- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.........- - <br /> Septic Tank (Specify Requirements) - ----------------- ------'-------------- ......:......................... -- . --- <br /> Disposal Field {Specify Requiremenfsl................ .... _. - <br /> - --------------------- - <br /> �: <br /> . i - <br /> 'P -- " - <br /> ,r ..-...----------------------- <br /> (Draw <br /> .- �e,- —ter.:." <br /> 'tr ' (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the workwill b�e <br /> 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: i <br /> 1 <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 become subject to Workman's Compensation laws of California." <br /> Signed----...-- d - :......... ........... Owner i ri <br /> BY-_----_---_ = ----------------- --------- - Title.__ -" f�- - <br /> Jlf other than owner) - <br /> A F DE ARTMEUSE ONLY <br /> APPLICATION ACCEPTED BY.............. ------- ^^�-- -- .. ..... .......DATE �� g 7. .... . . ... . <br /> DATE......... <br /> DIVISION OF LAND NUMBER..... <br /> ADDITIONAL COMMENTS......... ..... -------- ----- .... --....-•--- ..-- <br /> �r• f <br /> ..........................�...... ........_._ .._../..f....-.-._----......_.._..-----..._......-.:--_..........--_-...-------.....-__._.---`--.-...-..__.....- _....___.__......._...__.... <br /> .................................... ... C/ ------ __...-.._.......-...._..___._.._.._.....__--------..... <br /> .... .................... Date--.-...._..-.. ._ F <br /> Final Inspection by:...._.1._._ - ----------------- <br /> EH 13 2 SA JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/76 3M� <br />