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FOR OFFICE USE: FOR OFFICE USE; <br /> k APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No,.7. _"-fD <br /> ----------------------------- .......... ....•--- -- �.— � <br /> ..--•-------- This Permit Expires 1 Year From Date Issued Date Issued_v�.._ <br /> Application Whereby made to-the San Joaquin Local'Health District for apermit to construct and inst3 le work herein described. <br /> This application is made in lance with County Ordinance No. 549 and exp ting Rul s and Regulations: <br /> JOB ADDRESS/LOCATI NJ..a- .._.. h./a.!^'- /J ------------.CENSUS TRACT------- --------• -- <br /> Owner's: Name...-�7 �D/ -.fit----,A ...._- .......... � Phone <br /> .. -- -- . .. .. -- -------------- ..-. ..-_---------..----.......... <br /> Address- . U <br /> --- �� <br /> ... tY------� ---------- Zip----------- <br /> i Contractor's Name. %1-12 .. .... . - - .....---.License_,L5?1"._h._,?/ ..Phone....... ---------- - - <br /> fnstallation will serve: Residence ❑ Apartment House ❑ Commercial Q ilei Court ❑ <br /> / Motel ❑ Other... .. ........... ,. <br /> Number of living units:.._...! - Number of bedrooms-...---. ...Garbage Grinder.._.'... _Lot Size...-. I,, <br /> Water Supply: Public System and name-_ ....._------------- <br /> ---- --=--------- - -......,._.....-- •----- ---- - - -r. -�-�--.. .-•---,- <br /> ---- ... . •----.-.Private <br /> Character of soil to a depth of 3 feet: l Sand ❑ Sift E] Clay L] Peat Sandy Loam 0 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 [ } SEPTIC TANK f�} Size .... .... ..... c <br /> - ------Liquid Depth. <br /> Capacity..-1- .. - •Type- !_'! -. -- -.....Material -- ----.-...moo. Compartments..-._.:. <br /> Distance to nearest: Well_'/b0- f__. Foundation...- �.�.�-�^-Prop;-Line-.... <br /> LEACHING LINE [ Y/N_o­of Lines ----------------Length of each line------- b.--..--.-_-Total Length .. o *� <br /> f g <br /> Distance to nearre a Filter Material... _ Depth Filter Material.. ---_ /_ pp. ......._..._._.... ................0 ` <br /> D' Box. / YP / p /(� �-�--- <br /> t; . <br /> F st. Well--,t - .----.Foundation----.. .............Property Line.---- <br /> SEEPAGE PIT ( ] Depth---- ----------- eter--.�'�-- -...Number-------------------------------- Rock Filled Yes ❑ No[, <br /> I <br /> Water Table Depth---------------------- ............ --- -----------Rock Size--. ....... -•----------- <br /> Distance to nearest: Well............... ...........................Foundation--..------..-- - ....Prop. Line.--------------------- <br /> ..-- ! <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...----------•-.-.........-........ ...............Date__...-............. _ .---} <br /> Septic Tank (Specify Requirements)... . ......... .------------- <br /> Disposal Field (Specify Requirements). ...... ....... ----- <br /> ...............• ----.. ­------------------- :ll <br /> ....--•------ ............. <br /> Dr <br /> { aw 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 Count 4 <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agent <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner f <br /> to become subject to Workman's Compensation laws of California." _f- <br /> Signed......... <br /> <.-.....-, . Owner , <br /> BY--------- ------ <br /> . Tifle. <br /> --- -----�__--"�''........................ <br /> [If other than owner] <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- ........ DATE -----A—/S:77 N- -- ---- ----- ------- <br /> DIVISION OF LAND NUMBER .... .� DATE.... <br /> ......... --- ------ ---------------------- ------- <br /> ADDITIONAL COMMENTS .................. <br /> -------- ------------ <br /> ----•-•..------------------ .......... --------------- -------- ............ ......................... ----------------- -•-------- ......------....------------....------ ---- ..... <br /> -•- ------------------1­- ---...... <br /> Final Inspecrron by ..... .... .... ------------------ -....----------- /' Date--... ... <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/76 aM '. <br />