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FOR OFFICE USE: Y100, <br /> ,/ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> _....-'----'--- ---'---------- - -------- -----•-•' Permit No.. <br /> (Complete in Triplicate) Z 9.1,�,5— <br /> '------'----'------------ ---------- ----'- ...--'•---" Date Issued.-cP.-��.._.7/ <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•complian cerwi.t.h.Cou/►nty-Ordinance No. 549 fcind existi g ules a d Rpgulat"ons: <br /> JOB ADDRESS/LOCATION -------------CENSUS TRACT........-._.._. :.--..._....... <br /> Owner's Name. "`�...�h_G -.. .-- ....: " Phone. . r .-' "---'Address <br /> ---' <br /> �J .... ........... • .. <br /> `. <br /> Address_ - -------f�-.---- - _47..... .............. Cih' " 'r Zip <br /> Contractor's Name---"-' -- -� j. _- .............. .....--.License # G. S /_. .Phone- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial K�- T�ailer Court ❑ <br /> Motel Other..... ' <br /> Number of living units;................Number of bedrooms............Garbage Grinder.-..------_.Lot Size..... . ...... A7-. --- <br /> _ .. <br /> Water Supply: Public System and name. ---------------- - --------------------------------------Private; <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peatandy 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 /> PACKAGE TREATMENT [+"j SEPTIC TANK [!�]— Size'p� (�_. <br /> -- ----- �--��--��-�_...No. CompartmentsidDepth.--. --'............. ` <br /> Capacity-�� � °Type---- .;:._----.Material- c _0.1 <br /> e� <br /> Distance to nearest: Well.-..--.r.G-:°...r.---'--.. .-.------Foundation--- _...._.....Prop. Line.j 1/........ <br /> .---- ^ <br /> 1J ,'• <br /> LEACHING LINE <br /> [ ' No. of Lines ......... ............. eac ina..... X� O - Tata] Length " - ' .��4 ---- <br /> t ` '_".' r <br /> D' Box. _e_5 -:Type Filter Material..Ylz.�(�.... Depth Filter Material-- ._-_-_. . <br /> -Pro Property Line..-- - ................ <br /> Distanc to nearest: Well--/-P-t? .:�__ Foundation.- a.�.. p y / <br /> SEEPAGE PIT { ) Depth..................Diameter------------------ Number. .......=.--':---------....._._ Rock Filled Yes ❑ No <br /> Water Table Depth. - ------------- -----------------•-----`Rock Size--------------------------------------------- -- <br /> t <br /> Distance to nearest: Well................-.....-.............--------Foundation................ .........Prop. Line.-.-----.....-......._--- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.........._____''------------------- ------------ �Ddte.--.----.----.-.-_.-_......_. <br /> Septic Tank (Specify Requirements) `- ------------------------------------------------ . --- ...... ................ <br /> Disposal Field (Specify Requirements)_................ . -� ^ -' .................� .._�' <br /> ---•--•--------------------------------- ------------------ ---'----- . ---------------- ......... .... . --------------I............ <br /> -------------------------' <br /> {Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and—that'.—the-work'_`will--be-done..in "accordance with San Joaquin Cour <br /> Ordinances,`State" "Laws,'pnd"Rutes "and• Regulations of the San Joaquin Local Health District, Home owner or licensed age! ; <br /> signature certifies the following: <br /> i"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-J <br /> to become subject to Workman's Compensation laws of California." �'�� <br /> Signed--"- ----------- .... ----------------------_Owner <br /> BY--I---------------._.-....... / - ._...._._ ...... Title. " j '-- ......... ------- <br /> (If other than owner) e <br /> FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BX --- <br /> --......DATE �---... ..... ..........-- <br /> DIVISION OF LAND NUMBER----------- � .._DATE ..__..-----_. --------- <br /> .... <br /> ADDITIONAL COMMENTS.--------' ........ ------......... ............. .. <br /> ..................... - ------------ -------------........ ................. .......---....... ............... --•--•------------------------ . ............................. ....... <br /> I <br /> --------------------------------........................... -- -----------•---•------- ---------------------------' ----'-' -Q' - --- . ._. ..----- <br /> ,- <br /> Final lnspeciion by:.... -... t-------------------------------------- ------------- -------- Date.'.. <br /> I.......--" ---...--... . <br /> EH 13 24 l SAN JOAQLIIN LOCAL HEALTH D �RICT Fay 21677 REV. 7/76 3M <br />