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FOR OFFICE USE: FOR OFFICE USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> %f"-/S7 <br /> ......................•--- - <br /> ------ -- .--- -------- - y <br /> .w=Y••_.'- �1, [Complete in Triplicate} Permit No..............-. ....... <br /> ............................ .............. ........ . 7� <br /> Date Issued...3..-...a.-...�--- <br /> ...................................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the Son-lJoaquin 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/LOCA ON------_..-- . ... .� ..�" ' ...--------------- ..........CENSUS TRACT-_---- ------------- ----.--- <br /> 1 , <br /> Owner's NameQ � 1 :-.... :--....Phone -- <br /> Address-...- �. ., ......... ....j City.-.' V1... Zip = ;.... <br /> Contractor's Name.-.-- _: PayLicense #. "3" '�5.Phone-------------------------- <br /> Installation <br /> ---------------------- -Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- ------------------ - --•----------- <br /> Number of living units:___._.-.,_..---Number of bedrooms-....Garbage Grinder------------Lot Size----tUO ���d-_-:,--- _- <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 /> 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.) <br /> NEW .INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> f <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ) Size------- --------------------------------------------------Liquid Depth..::- ........ --.-i? <br /> Capacity------ ----TYPe--------- ----------- Material-------------------.......No, Compartments...._. --.....--- -----V1 <br /> a <br /> Distance to nearest: Weil--- ------------ ------- ---- ---------Foundation.------ -- - ......._.Prop. Line---_-----------_-------t' <br />( <br /> LINE [ ] No. of Lines - ---------------- ----Length of each line •-----------... Total Length ........- ------_---_-------. a LEACHING ---- --------•--• ------------------------ <br /> 'D' Box......_.: .Type Filter Material....................Depth Filter Material-...._- -._. <br /> - <br /> Distance tonearest: Well............................Foundation----------------------" -- .Property Line................................. <br /> SEEPAGE PIT [ ) Depth............. ...Diameter--------------......Number---------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth--------------------------- -------.Rock Size--_------ ----- - ................. <br /> Distance to nearest: Wellf.................. ...-.--------Foundation.-----_-_---..........Prop. Line---------.-..-- -----------. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.....�T.O� ......... <br /> ...............Date_...--.-:......._......--------.- ) <br /> Septic Tank (Specify Requirementsl.:.... ........ <br /> 1 Disposal Field (Specify Requirements)_ ___._ra d.. ._. ..._.�.~...3`3.__- -�.- ' <br /> ------------------------------------ <br /> ------ ------------------------ <br /> •-------------------------------------- <br /> ------------------------------------------ <br /> ----------------------------------------------------------- <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 land 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 tithe 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 Taws of California." <br /> Signed------ ------------- ------------D. A. PARiSH SQ"�Sa..�NC.-------- --Owner <br /> POST OFFICE BOX '1650 <br /> i , - Title.. --•------------- - ----------- --------------_- <br /> B ..----•-•--------------------- <br /> I Y - STflE:f(TON;-C1kt�Fflt;;hY-�i--9�--.-....--�- <br /> (If other than owner.) <br /> F R. EPA MENT USE ONLY <br /> APPLICATION ACCEPTED BY------------- �......-------- - DATE <br /> .....--3 <br /> DIVISION OF LAND NUMBER.-------- ----------------- ................. DATE.... -------------- ..-, ..... ----- <br /> ADDITIONAL COMMENTS _....... ......I ...-----• ... ...---- ------- ---------------- ----------------- ..._.....----- ---... <br /> ------------------------ <br /> I -- ----------.......................--_-........... <br /> ------------------ <br /> --------------------------- -- - - <br /> ----- --------- ---....- ----------------- ---------------- <br /> ' ---------- -•-•-•..................................... --.... ---------------- <br /> Final•Inspecfion b „."•1' Date. . ...... ........... <br /> EH 13 24 SAN OAQUIN LOCAL HEALTH DISTRICT F65 21677 REV. 7/76 3M <br />