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FOR OFFICE USE: , / FOR OFFICE USE: <br /> f/ APPLICATION FOR SANITATION PERMIT <br /> •.................... <br /> (Complete,in Triplicate) Permit No.-Z _-�--- --.. <br /> Date Issued./:_1?5-*7.. <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. 36_�._�/!tJ.... .. . ST�Ki[/.------ <br /> - ----------.CENSUS TRACT....... <br /> Name---- -9. Phone............... <br /> yla -B T7/ <br /> ------ . ....... ...................... .,.... <br /> Address--------- � 3 .E...__ fNCf T...- -- --------- ------------------- --- .........City-------STk'v...... ................zip------------- ...-------- <br /> Contractor's Name p IPRIS/1-_g�..5��t�s-.......... . 3 ����C1d o <br /> -----------------License #? ...�'�a ... .Phone <br /> Installation will serve: Residence's Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--------------------------------------------- <br /> - So � <br /> Number of living units:.......-------Number of bedrooms...f?--...Garbage Grinder............Lot Size................ ..X-� .------ <br /> Water Supply: Public System and name.............L*/ ------------.----- ............................... .................------------------- -------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ <br /> Hardpan ❑ AdobeX 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,] 'ILV <br /> V <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size...................... ------------Liquid Depth------................... <br /> �r�, <br /> Capacity.... ........... ...Type----------------..--.--Material----------------- ........No. Compartments__------------- ----- �V <br /> Distance to nearest: Well" - 4.- ................Foundation.......... . ... Prop. Line.......................... <br /> .•. <br /> LEACHING LINE [ ] No. of Lines ---- --------- of each-fins---------------------------Total Length .. --------------_-----..----......... <br /> 'D' Box-....... ...Type Filter Material........ ..... ....Depth Filter Material------------------------------•--------- ----------------------- <br /> Distance t eno asst.„,Well--------------------------- Foundation------_----------------...Property Line..-............_-.... <br /> SEEPAGE PIT [ ] Depth---___.......Diameter--------------- Number-------------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth------------------------- ---------------------------------Rock Size----------------......-------------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation ----------Prop. Line.---.------ -.- _-----.-• <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....---.---`lo. =-a.z..:'........ ..Date.................... ------------------_) <br /> Septic Tank (Specify Requirements).-- F.. ------------------F.-...--. ----------------------------------------------............. ----------------..............--.- ------ <br /> Disposal Field (Specify Requirements) . �t1STA[.. L ;33'��{ _�"_.:/ fir _.Ve - I—&,I, !Y L mcg------------ - --------- -------------- <br /> -----•--....... ................................... ------------------•---- <br /> k.� -------------- - ---------------------- <br /> - ........................ . . _ - - - <br /> {Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed-... �f,�i✓�...... -- --------- ---------------------------------------Crwner <br /> �/ � `'t- �..... Title EST/�ta7 ,1 .... - ---- •......... ---- <br /> (if other than owner[ <br /> OR EPART NT USE ONLY <br /> APPLICATION ACCEPTED BY_......... '�'r`. °�� ......-----DATE ..--- � ---..�... � ..-..... <br /> DIVISION OF LAND NUMBER.................. DATE.-.----____-- -.-• <br /> ADDITIONAL COMMENTS......................... ................................................ .. ........ . <br /> --------- <br /> --------------------------------------------- ----- -------------•-----------•------------------------------------ --- - ......... ..... <br /> ---------- --------- -----•---•----------------.:...--------....-----.-..._...------------------ ------- •--- -------- .--- ---.------ <br /> Final Inspddion b �� - U1 ---Date------� Z ------------ ------ <br /> -� .. - -----•- -------- ---------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&5 216x'7 REV. 7/76 3M <br />