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FOR OFFICE USE: FOR OFFICE USE: <br /> T <br /> /APPLICATION FOR SANITATION PERMIT <br />. <br /> ------------------------------------ --- ----- - <br /> (Complete in Triplicate) Permit No----7___.':. � <br /> -------------------------------------I--------------- -- . �- 7 <br /> --- This Permit Expires 1 Year From Date Issued 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--- -- ------- ---L-l.. �._ _ --- -------------------- ----------CENSUS TRACT.----- -------+ <br /> Owner's Name............... . . .. _ <br /> vvl_. ,P, L� Q'----- --- �----------------------- Phone_��6'.'4�6 <br /> Address----------------- ------ l� 1 ----- = 4"L.4u.ca.,r--. City---- ---- - ---- -- ------ZiP-------------- -- ------------ <br /> Contractor's Name------- ---- --�--------------- - License # <br /> Phone_ 1717.6 _7----- -- <br /> Installation will serve: Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ 1 <br /> s. r Motel ❑ Other00-1 e-9------------------------ <br /> Number of living units:----------------Number of bedrooms------------Garbage Grinder------------Lot Size-------- _..._--:-___.____.__.___.____,_.. <br /> Water Supply: Public System and name---------- ------ ------ -----------.-.------------ ... --------------------------- . ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ ' Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> i 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.) J <br /> NEW INSTALLATION: `(No septic fnk or seepage pit permitted if publicsewer is available within 200 feet,] <br /> lSY <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [�Q Sizex._:_.r __.< _x_ - ------ Liquid Depth-._______________________ <br /> � : t MatriaE-__ -------No. Compartments--.--.- ___________Ca acitY-� -- - TYpe_ �-��1"__ te. <br /> [ <br /> Distance to nearest: Well_. ------ �. - ._ 7A := Prop. Line 6. <br /> __ Foundation.__�___-� <br /> LEACHING LINE ] No. of Lines-------- -- -..Len Length <br /> of edc- _lms------- ,..__._ otal,Length------- -----------=------,--.-----'-- <br /> t - f r -_________._____.__. <br /> `D' Box Filter Material—____Depth F Iter Material__ �� _______________________ <br /> nvi <br /> i. Distance,to wrest: Well---------'----`-------------Foundations►i-�--�_---I--- *L----Property Line----- -------------------------- <br /> . <br /> SEEPAGE PIT '�� Depth _ ____._Qiameter_�_ ._ Number__ l._ Rook.-.Filled Yes, No❑ <br /> i <br /> Water Table'Qepth t ----------- ------ Rock Size . �LCZ - .�'' <br /> Distance to::neiaree#: Well-------------- ` - _Foundation-_:, .x # ro , ---- <br /> ka_ Qro Line - <br /> REPAIR/ADDITION (Prev Sanitation Permit#`" '" D to-""'--- - �-� -------- ] <br /> -- - -- ---- <br /> r -14 <br /> Septic tankw(Specify`Requirernents]' _ _ a - -- ---- �' --�- -------- <br /> � � E'=---- <br /> �. �s '� <br /> DislposalField (Specify Requirements)------ -------------­ --------------------------------------I---------------------------------------------------------------------------- ----- <br /> Ii <br /> t .. �„ <br /> . .__ , <br /> ---- ------------------------------ ---- ----------------------------------------- ------------------------ <br /> ------ <br /> ------ ------- <br /> - s ----- -------- <br /> --------- ------------- -- <br /> -------------------------------- ------------- <br /> ----- -------------------------- ------------- Draw existing and required addition on reverse side) <br /> I hereby certify that l 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-- ;---- - ---- -------------Owner <br /> BY ` ✓�1 c----- --- -- -- -=------------------- Title <br /> If other than owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ ------- ----- =__Q/fiTE 77�----------- <br /> DIVISION OF LAND NUMBER-- ----------------------------- DATE. --------------- ---------------- <br /> ADDITIONAL COMMENTS_/QeC.elrtc - 4 / Am <br /> .� <br /> " _x771[-�- _ SYism 'JE::, �e�; <br /> I <br /> ----------------------- ------------ ---- ------ ----- ---------------------------------- -------------------- ------------------------------------------------- ----------- <br /> Final <br /> ------- -_ <br /> FinalInspection by:---------- -- ------------------- ----=--------------------------------------------------Date------ ---------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT - ras 21677 Rev. 7/76 3M <br />