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FOR OFFICE USE: FOR OFFICE USE: [ <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------- --- r- Permit Na..77_,_, f_ a <br /> (Complete in Triplicate) <br /> ----------------------"---- ---- - : <br /> ' �N Date Issued.......=-z-�- 77 <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 Co ty Ordinance No. 544 and existing Rules and Regulations: 1 <br /> JOB ADDRESS/LOCATION--- l+_S'3 ------- ---=--=-=------°: -----.--- ----------------CENSUS.TRACT------ <br /> ----O0 ner's <br /> wner's Name-------- , - s. ------------ ----- -----=----------- <br /> Phone--- <br /> ------ <br /> hone ---� 7 <br /> Addres's ��- -- ----: -- s .----=-' ------� -- -- - -� - .--------City --------- --Zip------------------------------ <br /> Contractor's Name--'------ - - .- .-.--r------------- ------ ----=---:-=-License #__a_�lS_ _p_ _Phone-.Ll `� /�---- <br /> Installation will serve: Residence b4�1�Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> . rrNum <br /> .. ' 'Motel-❑ <br /> Other---, =----- - ♦ 3 , <br /> Number.of livin units:__,;,._[.;__" Nu ber of.,bed oms:._tX Go bag a Grinder....`._..-.-.Lott Size.__-, _ -=_X '-... <br /> Water Supply: Public System and.name .. :. ' `- ------------- ---"---- - : , _ ---------------------------Private ❑�"`� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ I Peat ❑ Sandy Loam ❑ :Clay Loam ❑ <br /> (� <br /> Hardpan ❑ AdobeFill Material_ _ <br /> .. .._....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 tonk .or seepage pit permitted.if public sewer is available within 200 feet,) ; <br /> PACKAGE TREATMENT- -]' '-SEPTIC TANK [ ] Size- -'----------F--------------='--------------------- ~Liquid Depth ---------------------- <br /> capacity-------- <br /> --------------------`Capacity--=--------------------Type-----------------------Material----------= -----------No. Compartments----------------------------=------- <br /> _ d Distancs'to nearest: Well------------------------------ ----___,—Foundation--------------------------Prop. Line--------------------------. <br /> h <br /> LEACHING LINE: [;] �o.Bo Lines==_T a Filter Mateeagth of-_each 11De th Filter Material--Total- Length.:•a_____-- ______________.,_-,....._-. � <br /> ] .-Type P. ----------------------------- <br /> Distance <br /> -------- ---------- <br /> ! Distance to nearest: Well-:--------------- ----------Foundation-------------------------'----Property Line_---------------------------------. <br /> SEEPAGE PIT [ ] Depth-----------------Diameter----------------,----Number-------------------.--. .-- Rock Filled Yes ❑ No ❑ <br /> t (Nater Table Depth- ;----- - . - -------.Rock Size------ ----- <br /> ----Foundation--------------- ------- -Prop. Line <br /> nearest: Well-------------------------------- --- -"-. ? <br /> REPAIR/ADDITION (Prev; Sanitation Permit#------- ....................r------:--------------Date-------------------------- '---------} <br /> Septic Tank (Specify Requirements)--- --------=-----------•---------------------- f --------- I <br /> Disposal Field (Specify Requirements[ __ -'-/ ------------- - --- -` l-. -`3 .-.--- --------------- <br /> , <br /> a . <br /> "1 # <br /> --- ---------- --- -s------------------ ----- -- ----------- ---------------------------------------------- <br /> (Draw existing and required addition on reverse side) [ <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 i <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 beco bject to Wo an's ompensation .laws of California." o <br /> Signed ^--- ----- ----- -- -t-------- r --------------------- <br /> --- <br /> ------Owner 3 <br /> BY-1 ------L . J= ---- :Title-------------- <br /> (If other than'own r) ' <br /> FEP#IkTMENT USE ONLY F <br /> $ <br /> APPLICATION ACCEPTED BY-.__------ _..-- --- - --- -- =--=--- - ------=----- ,.------------- DATE....- z <br /> DIVISION OF LAND NUMBER- = ----------- - - DATE _ <br /> ADDITIONAL COMMENTS.-------- / r1• I ----- <br /> D;as . <br /> ---------- -------- ----- <br /> ------------------------------- -- ---------------------------- ----- ------------------------ <br /> ------- <br /> i <br /> - = ------- ------ ---------------------------------------------"-=---------------------------------_-- -------- ------------- <br /> ------------------ ------------------------ - - --- ---------=--------------------------------- <br /> Date---- = -------------------- <br /> Final <br /> Inspection by=- --------=-`----------- <br /> ----- - - - i-- ---------- -- - - -------------------------------------------------------- � '� <br /> I EH 13 24 4 ; SAN J QUIN LOCAL HEALTH DISTRICT Fassis 7 REV. 71763M <br />