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FOR'OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ldS� � <br /> --------------------- ------- ------- Permit No.,79--------------- <br /> ------------------------------------------ <br /> - - - a <br /> (Complete in Triplicate] ----- <br /> Date Issued__1v�-7?4.-l.7- L'5" <br /> --------------------------------------------------------- This Permit Expires1l 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- .=- --------------- <br /> = _ ----------- f - ---=---------------------------------- ------ - CENSUS TRACT ------ -------------------- <br /> Owner's Name. `------ -- --'-----Phone------------------. --.:---=----- <br /> - - - - _ q. <br /> Address. - / .----------.-------- -------- --------------City-------1 /�- ----------------------.Zip---_------ ------------- <br /> x actors Name----- - ----- -------eel -:7171- �� - neContrL'cense #. �Z Phone <br /> Installation will serve: Residence e Apartment House ❑ Commercial ❑ ;Trailer Court ❑ <br /> t Motel F7) . <br /> Other;,t=.:.._.Number of living units---_---.---- ---Number of bedrooms. � Garbage'G- <br /> rindex .Lot Size--------------- ------ -------------------- <br /> Water Supply: Public System and name-- -:_-._ -- : _ - -".--.-- -,?. --- - ------ x- - --- --Private <br /> Character of soil to a depth of 3 feet: - Sand ❑ Silt Q'. Clay ❑1Peat:J] Sand Loam [ Clcry Loam ❑ <br /> Hardpan ❑ ; Adobe❑-Fill Materiel'- - ----.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§eptic tank or seepage'pif'permitled •if­I56blic sewer is available within MO feet,] ' <br /> iz.e_ - ____ _ <br /> ------------ <br /> PACKAGE TREATMENT -CapacSEPTIC TANK =-:Ty _______ ___ - --- Liquid Det ---------------- <br /> -------------- <br /> -- -- -•------- <br /> ---=--------- Material _-y'- W= = _ :No.-Gompar-tments=='.�-__: =-- --------------- <br /> Distance to nearest: Well ------ <br /> :-_ Foundation:-----:-- __.-- Prop. Line--------:-_----------- ----- <br /> LEACHING LINE [ ] No. of Lines-------- _ _ _ --------Length of each line_'______ _,___ _____Total Length -------_-------------:_-____.________9__ <br /> D' Box..::-_. =::Type Filter Material --------------------Depth Filter.Material:----------------------------------------------------------- <br /> r <br /> ,. ----------Foundation---}--- 3------ -------Property Line--------------------------------- <br /> - <br /> Distance to nearest: WeiI__ ' <br /> SEEPAGE PIT y <br /> [ ] Depth_ ; _..: Digmeter_ _-_-Number----- -_--_ -_-_-- Rock Filled Yes ❑ Na ❑ <br /> WaterTable Depth ----------------------------------------------------------Rock Size.------- ---------------------------------=----- <br /> REPAIR/ADDITION (Prev Sanitation Permit#Welt-- -----=--------------- --------------- <br /> -------------------------------------Foundation___ <br /> Prap. Line ----- ---- -- . -. <br /> Date <br /> Septic.Tank (Specify Requirements))----- - -- --=-----------=- = -- = ------------- -- <br /> s <br /> Disposal Field (Specify Requirements)_.__ - R �--r-----___--------------__.----___.-_--.----. _ <br /> -- =-- --- - ---- - <br /> k fv <br /> ` k /o <br /> (Draw existingpnd re wired addition on reverse side[ iF <br /> I hereby certify That:l have prepared this application and-that Ae 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 w <br /> signature certifies the following: i <br /> I <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 io.Workman's Compensation laws of California." 1 <br /> Signed-_ - <br /> �j r wn .•,�,. <br /> BY -'- -- ` ------------------ t/ J_' -Title .�. 4 1__In---I----- ----- --- <br /> i <br /> !C <br /> (If other than:owrierJ <br /> FOR'DEPARTMENT USE ONLY _.. <br /> APPLICATION ACCEPTED' BY.- = _ --- -------- --- ---------- ------- ---- ------------------DATE _/.---- 6 ------------------------ <br /> DIVISION OF LAND NUMBER -- DATE.: <br /> ----------------------- -------------------- ----- -- --------- ------- -_--- <br /> --- - <br /> ADDITIONAL COMMENTS.....=-------------------= - - --------------=------------ ---- -=-------------------=--- --------------------------- - - -------- -------------- ---- <br /> -----=------ --------------------------r-------------------- --------------- ------------------------------------------------------ --------------------- --------- ---- -------------------------------- <br /> -------------------------------- ------------- ------ -------- ----------------------------------------------------------- ---------------------------------- ----- -------- <br /> Final Inspection b ..� ,---- __._._ . _ _ , _ • Date. f-�-/ �- <br /> ------------------------------------------------- <br /> ey 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas lien Rev. 7/76 aM <br />