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FOR OFFICE USE: FOR OFFICE US' <br /> "APPLICATION FOR SANITATION PERMIT '+d/ <br /> ------------------------------- -------- ------------ No.77 <br /> (Complete in Triplicate) Permit <br /> ---------------------------- 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 herein described. <br /> ,,,this application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION---,2-s'5-7 ��J�--------------------------------------- <br /> CENSUS TRACT. <br /> —Owner's Name...- -------- -- `� '�- -------- ---------------------------------------- --------Phone.--------- ------------ -- --------- <br /> Address -----------�.=rS7 D-_. -� ------- -----------city �� -Zi <br /> P <br /> Contractor's Name--_Cp �'^--- -------------------License #--3 -R Z-?=A---Phone--------------------------------- <br /> �' ----- -------- <br /> -Installation will serve: Residence 2� Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----- -- ----------------------------------- <br /> Number of living units:._---/--------Number of bedrooms__. .Garbage Grinder-.---.------Lot Size-------------_-.---.....--___.-_-_--.__.___.-_--_--___ <br /> rWater Supply: Public System and name---------- ---- -- ---------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet:/ Sand E] Silt E] Clay E] Peat E] Sandy Loam ❑ Clay Loam El <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 <br /> if public sewer is available within 200 feet,) <br /> 'PACKAGE TREATMENT [ ) SEPTIC TANK [� Size__-L / _._/X_!_�_X___.3— ./ <br /> -- f� j <br /> Liquid Depth Z - <br /> Capacity-.. - ----Type- ----Material-__ ------No. Compartments...- <br /> ----------------------------- - <br /> Distance to nearest: Well----- Foundation._____L_b--`_-_-----__-.Prop. Line_____s.-__-.-.---._-__---0 <br /> r <br /> LEACHING LINE [Yf/ No. of Lines-.------._y__-_---.-..Length of each line----------cl.i�_---______Total Length ------To----------------------------- <br /> 'D' Box___ ____Type Filter Material------..-_J�___-.Depth Filter Material------1__/-----------------___----_--_-__--.-___--_-_---O <br /> i <br /> Distance to nearest- Well----------- S?_-I-------.___Foundation.--.__-__l_-L.__`-______Property Line--- --__---__ <br /> SEEPAGE PIT [ Depth-----Z -'-Diameter_ ----- --3-rt_-Number.....__-___-_z_-_________- Rock Filled . Yes (�No E)2/ ,l <br /> Water Table Depth. ��C -----------------------Rock Size !� --X-------------------------- <br /> Distance to nearest: Well----------7-!Q!P..._-------------------Foundation---- -._.l.-O-.---..-_-.Prop, Line______ _________.__-_ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_.._____.____________.-.._--_-_---_-____..Date.---------_----_ <br /> -- - <br /> —Septic Tank (Specify Requirements)-----------_------------------------------------------------------------- <br /> --------------------------------------------------------------------- --------- <br /> Disposal Field (Specify Requirements)-- -- ---------------- --------- ---------------------------------- -------------- ------------- - -- --------------------- --- ---------- - --------- <br /> S <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 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 <br /> y to become subject to Workman's Compensation laws of lifornia. <br /> Signed----------------- ----------- ----------------- -- � Owner <br /> _. BY------------------- ---------------------------------- TG'2 -- --`- -----�----2l Title.-- 1 <br /> r <br /> --------- ---------------------------------------- <br /> - <br /> (If other than owner) <br /> FOR DEPARTMENT USE O LY <br /> APPLICATION ACCEPTED BY---- _ --- -- -= - -------- ----- -------------------DATE ----- - �----7 <br /> DIVISION OF LAND NUMBER_ -- - ---------- --- - --- -------------- -------- ------------ ---------- .DATE --- -- --- ---- -- --------------------- <br /> ADDITIONAL <br /> ------ ---- - ------ <br /> ADDITIONAL COMMENTS ----- --- -- ---------------------------------- <br /> - <br /> --------- ----------------------— --------- ------- ------------------------------- -- ---- ------------------- ----------------------------------------------------------------------------- --- - -- ------- ---------- <br /> ----------------------------­--------------------------- -------- ---------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------- <br /> Final Inspection by -- { d Date----- - --- - <br /> -------------------------------------------- ------ <br /> Final _- - ---- -------- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />