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} FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete-in Triplicate) Permit No._.7�'_ _V� <br /> �.. <br /> IDate l Is'sued__�?�_' 1- <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. <br /> - <br /> ---el� , __J <br /> -- <br /> --------------- ---------------- ---- •---CENSUS TRACT----- ------------------------� <br /> Owner's Name__ -- --- Phone <br /> Address---- - ------`' i�/ �f -----` - - ------City ��..3� <br /> ZIP --- <br /> 'Contractor's Name-----L_/1?R./q_y-_-1� eldl-fj�_ i✓ --.e-7-'e-------License #_4_73:34=6---------Phone-z-/---�/7�--- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other -------------- <br /> '�V <br /> Number.of living units:-.,--/-------Number of,bedrooms-.---Garbage Grinder-- .'---Lot Size..........._ r/ <br /> x� =;;, <br /> Water Supply: Public System and name---------_-__ ---. _ . _.---------------------- Private <br /> .------ <br /> _ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ <br /> Hardpan Adobe Fill Material-_ ---------If yes, type________________ _ <br /> i - ---------1---- <br /> 4. F - <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 avail ble within 240 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANKI ] <br /> Z, <br /> Size Liquid Depth 4 <br /> Capacity/_?"' __Type/7-T- Materia l IVlataria �?.�.- G' Jo. Compartments___ _-- <br /> Distance to.nearest: Well------__"W42_ _.-- ------------ - <br /> -- Foun ation..-..._ .-�---------- Prop. Line-,--- <br /> LEACHING <br /> ine : --- --Q <br /> LEACHING LINE" [ ] No, of Lines--------- Z- <br /> Lengt f each line..------ -- Total Len* -------�� �--------------- <br /> 'D' Box /----Type Filter Material .-- _ Depth Filter Material.-_____-. _ <br /> r <br /> 9 <br /> Distance to nearest: Well--"-../ -__Foundation___--_��-- -----__-.Property Line_.--- ___________. j <br /> SEEPAGE PIT ` <br /> [ ] Depth.- __piameter..___3�-3-3:----- --___ f ock Filled Yes� No ❑ <br /> Water Table Depth----------- ---------------- <br /> ---------------- --- Rock Size-.-.----: <br /> i Distance to nearest: Well.____ _Foundation__---- _ <br /> ` Prop. Line---- - - <br /> REPAIR/ADDITION (Prev. Sanitation Permit#______________ .._________-___________:_ ".Date-__".---_____"---_-,_ ] <br /> ---------------------- <br /> Septic Tank (Specify Requirements)------- ------------------- - ------ --�---------- ------- ------- - ---------- --- <br /> Disposal Field (Specify Requirements)----------------- -- ----------------------------- <br /> -------- <br /> w <br /> ------------------ ----------------- --------------------- ---------------- <br /> ---------------------- ----- <br /> (Draw existing and required addition on reverse side) 3 <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 certifythat in 'the 1 <br /> performance-of work for which this permit is issued, 'I shall not employ any person in such manner as <br /> to beco sub' t Workman' Compensation laws of California." <br /> Signed------- ---- <br /> --Owner <br /> By-----=---- ---- -------------------- ---------------- ------------ ---- ------------ ---Title-------------------- - - <br /> -------------------------------- <br /> (If other than owner) ' <br /> FOR DEPARTMENT USE ONLY } <br /> APPLICATION ACCEPTED BY------ - _ ------------------------DATE --y- -�- --- ------ - -- t <br /> ADDITIONAL COMMENTS " -- r DATE-- ---------------------------------------------- <br /> DIVISION OF LAND NUMBER -----------------"-.--_ <br /> ----------------- <br /> `------------=-------- --------- ---------------- <br /> ----- ------------------------ ------------------------------ <br /> -- - <br /> Final Inspection by:--- - ---------- Date " -_ '1 <br /> i -------------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DIS RICT F8s 21677 REV. 7/76+3 <br />