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FOR OFFICE USE: !-// - FOR OFFICE USE: <br /> APPLICATION FO - <br /> R SANITATION PERMIT <br /> ------ <br /> ---•--------- (Complete in Triplicate) Permit No.Zi"_p4?_7 <br /> •------------------- ----------- •--._...-- Date Issued.�' <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 erein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing R iesn Regul ions: <br /> f JOB ADDR ESS/LOCATION_ .....�. <br /> i <br /> ^� CENSUS TRACT.- <br /> Owner's Name...... G�G-- . . Jam . - ............---: ..-_-------- -- - -------------Phone..... <br /> Address........... _ �Q.. $0.12----. CitXJl�'Ll- zip-, <br /> -- <br /> Contractor's Name-- ---- ---.-., -.-. . License # � .. P <br /> V - ---------- -------- --,---�� .. hone <br /> Installation will serve: Residence ❑ - Apartment House ❑ Commercial railer Court ❑ <br /> f Mote! ❑ Other.................. <br /> Number of living units:....:;`.-----Number of bedrooms.- Garbage Grinder...........-Lot Size.. -.. /" <br /> . / . .CIT-� -=-- <br /> Water Supply: Public System and name_- ......... ---------- --------------- <br /> - -- -------------------•---.......------ -------•---- ------ <br /> 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.oflot, location`of systeminrelation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted it public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ize..... - f„ --- --------- <br /> Liquid Depth. Z_Zt� .......... <br /> C-Y--•-- [� <br /> yppM 4--N . C -Capacity.1 .� . <br /> Distance to nearest: Wel!_:---------110------- ---- ----------Foundation.... Prop. Line... g <br /> LEACHING LINE [ No, of Lines _.... ----J----------------Length of each line-------------.-----------.---- Total Length ... ------------ --------- --------{.._. _..; `' <br /> t ...----- <br /> 'D' Box "e�,._Type Filter Material..�'D.�j,�..Depth FilterMaterial-....��.........................�..__._..... <br /> Distant/to nearest: Well------ <br /> Foundation.... ..... <br /> t ..................Property Line...-,.5.../......____..____ <br /> SEEPAGE PIT Depth. ............Diameter-.------.---..----- Number-...---------------------------- Rock Filled Yes ❑ No[ <br /> I <br /> Water Table Depth-------------------------------------------------_------Rock Size...-- ... . ....----- ------------•..:...- ^i <br /> Distance to nearest: Well----------------------- ------- --"-.......Foundation..--.-..-.-........ <br /> ...._..Prop. Line..-.....--...--..-.- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-._.... Date------------------------- ---- <br /> Septic Tank (Specify Requirements).-................... <br /> �I <br /> Disposal Field (Specify Requirements)...I__.......... <br /> ...........I—............. .............I------------- <br /> I <br /> I hereby certify that I have prepared this a lication and that the work will be done in accordance with San Joa Joaquin Count <br /> (Draw existing and required addition on reverse side) <br /> pp q y--- ; <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�b <br /> to become subject to Workman's Compensation laws of California." <br /> Signed------ -- --- - - - ...----- Owner <br /> --- ------ <br /> Qe------------------------- --- --- ----- <br /> BY ` ------- Title. <br /> f <br /> {If at er than owner) <br /> FOR DEPARTMENT USE ONLY , <br /> APPLICATION ACCEPTED BY------ ---- DATE <br /> DIVISION OF LAND NUMBER... ............. " DATE.... <br /> ADDITIONAL COMMENTS--. ....... -- ... <br /> --------------- ..- ..-."------....---- --- ----- ------------ ............. ......................................... <br /> I <br /> -------------- -------------- ----------- •-- ----------­------------- -- <br /> ..------- ---------•- - <br /> Final Inspection b �?9 <br /> y:.. . Date- .._ -r1-- - <br /> EH 1324 - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 SM' <br />