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FOR OFFICE USE: FOR OFFICE USE: <br /> PPLICATION FOR SANITATION PERMIT <br /> . _ ... - ._... Permit No.Z �.��.. <br /> (Complete in Triplicate) ' " <br /> 11_:0�..�r^..."..... 2-y------------ <br /> ............. -------------------.................. This Permit Expires 1 Year from Date Issued Date Issued-. 5 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> lis application is made in complia with County Ordinance No. 549 and existing Rules and Regultq ions: n �� <br /> JOB ADDRESS/LOCATION. �• ----- -'---- <br /> . ._-�� _ .....- <br /> .CENSUS TRACT.----- - ............ <br /> wner's Name. <br /> Phone - .............-- -- .....- <br /> Rddress----'_ .C.--- ---- ..City —. ------- "- Z'P -- <br /> -- - - <br /> Contractor's Name-_......`� "� �{ 7.�S,T'i-._ ,License #_J'ji. _-14_ "h,..J....Phone:. ,[y:.. E..'. 1�_.... <br /> ' f t _.. C' <br /> `stallation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--. -- - '- ........................ n ,� <br /> "umber of living units:_.._.f-_..---Number of bedrooms"......Garbage Grinder"."...._...Lot Size___.,,./".G�... (1 -.. .- -..--"._._.... .. <br /> k.ater Supply: Public System and name___.---------------------------------- ----._--------.--_------------------------------- --- ------ --------------------Private <br /> Character of soil to a depth of 3 feet: Sand p 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 /> "EW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ac <br /> .%CKAGE TREATMENT [ ] SEPTIC TANKiquiept .---.--..___ <br /> [ 1 Size ..._. ..... .--------------------------------------------Ld Dh0( <br /> Capacity_.... -------------Type--------------. __..Material..........................No. Compartments---------------------- <br /> �r Distance to nearest: Well---.-----_..._..._ .. . . .-__._.__.Foundation_.__-_.. . -_-._.. .. Prop. Line..... <br /> LLACHING LINE [ J No. of Lines . _ ."-.--_.Length of each line------ . ... _. .. Total Length _" - <br /> 'D' Box. . ..... Type Filter Material_. . ....Depth Filter Material .__---_ _. __..... - <br /> 1 <br /> r. Distance to nearest: Well---------------- -----.."_.Foundation----------------------------Property Line---------- --- _."- <br /> S_EEPAGE PIT [ ] Depth.......... .....Diameter----_._----_- ----Number_-.- _-.-___._..__..._-- Rock Filled Yes ❑ No <br /> Water Table Depth------------------------ .................-...Rock Size.........._-------------------------- <br /> 6. <br /> Distance to nearest; Well .....-..""..-__._ -------- ............Foundation....... ...........,...---Prop. Line-...-.......------._------. <br /> -PAIR/ADDITION (Prev. Sanitation Permit#...."_-...--"..."_-.."_- ------- ---------------Date__"_-..-_-_-- ---------- _____.._--_-) <br /> tic Tank (Specify Requirements)--------- ... --- ------- '.,' ----------------- ---.. <br /> Dis osal Field (Specify Requirements)...d." f' -�_ -Cr.-�". ..._� a.?�.$:.." ./3--- -. - --• <br /> _- -- - - - -- - - -- - - -q- <br /> -------------------- <br /> - . .c:.(4�...-<<--c.-...__ - - - - (�-- ----�---.._ . ...^- -- ..._al�L�:X----- {..-:."......./.r�'W7­ <br /> r .. .--------- <br /> raw existingand re wired addifiorfon reverse side) <br /> hereby certify that I have prepared this application and that the work will be done In accordance with S�o quln County <br /> 17rdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> 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 become subject to Workman's Compensation laws of California." <br /> "fined-- ' Owner �. <br /> ._.... Title_"_ ..-....__......... -- .- .... - ... -- ...... <br /> ( r than owner) <br /> f at e <br /> F DE ARTMENT USE ONLY <br /> 6APPLICATION ACCEPTED BY.------.-... . /L.c. ---- ---- J3.- -- ---_...----_---_... <br /> - ' -""—"_...... ..... --------.._DATE ."-... .. . 7� <br /> DIVISION OF LAND NUMBER.- - .... . -------------------- -...._. DATE.----- -------------- ....- ... ._...- <br /> DDITIONAL COMMENTS._.... �+� �"/� '� -------�1-.v8 ��-�--- 5-����8: �.. <br /> --------------- <br /> - - ----- ----- - YSN <br /> -- - .. ' ------------- --------- <br /> ---------- -. _. _ - - - _. . ..... <br /> - <br /> - - ' -- - <br /> /J <br /> nal Inspection b .... �U - ------ --------------------------------------------- - <br /> � y:.............. - - _.. ------------.....-------------------------- ...----.......Date... - - �Y _7.. - <br /> EN 13 2� AQUIN LOCAL HEALTH DISTRICT Fi.S 21677 REV. 7/76 3M <br />