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i <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No.7.. ..... -a <br /> Date Issued,-sr /.9 <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_-.ounty Cgrdinance No. 549 and existing Rules and Regulat}on�:. <br /> 0T X ,/ F� <br /> JOB ADDRESS%LOCATI N ��f. u...�!. ! ''< (rt�-f?'"-.-�'-'� .. .k -1't�z"�'y" �`, - - -CENSUS TRACT... <br /> Owner's Name........ � :t!�Y..t c�� j 'mac -,6............................. <br /> .... �......... ...-- -- --.- <br /> .. ---...Phone. -----... ....... . <br /> Address..... _ .. <br /> -4' City &Jv- - '' -4.0-.x-'-.� Zip r' <br /> Contractor's Name._.-.....------!?--rte! f' = ............................. <br /> ..License #..5.<.. .��- ----Phone.. ----- - - - <br /> Installation will serve: Residence E( Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other.------- --- ---.......---- --- - - <br /> Number of living units: ...'..- ......Number of bedrooms- -_- - .Garbage Grinder....._.....Lot Size.....-r <br /> up Water Supply: Public System and name..--............. ... ............... .....................---------.------.------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat(� Sandy Loom ❑ 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 [ ] Size-----------------------------------------------------------Liquid Depth ------------------..------ <br /> Capacity---------------------Type.-..... ...............Material--- --------- ------------No. Compartments--------------------------.---- --- <br /> Distance to nearest: Well -- ..... .........Foundation------------------------..Prop. Line- ----- -------------- <br /> LEACHING LINE [ ] No. of Lines-..-_--------- -..........Length of each line............................ Total Length.__.._.....__....._....----------_.._ <br /> 'D' Box-----------_Type Filter Material................... Depth Filter Material..........................-..------.-.------------------------- <br /> Distanceto nearest:Well-----------.................Foundation. _-._.............._--....Property Line..___----. ---.-----..--.---- <br /> SEEPAGE PIT [ ] Depth......_.........Diameter----_._.._......---Number---------.-----...------......-- Rock Filled Yes ❑ No <br /> Water Table Depth ---- - -- ---------- --....Rock Size------------------- ---------- - ------------ <br /> Distance to nearest:Well--------- - ----------------------- ------Foundation.__ .-.-----............Prop. Line------ ----.----- ------ - <br /> REPAIR/ADDITION (Prev. Sanitation Permit#___.. -_..................----.-----------------Date_._.-...____.. .--.-------- --------- --) <br /> Septic Tank (Specify Requirements)------I.. J,- -------------------------- --- - .........................­-­ <br /> Disp,osal Field (Specify Requirements).a �Sa�i _.. <br /> - - ---- ------------- ..................... ------------------------------------ <br /> ----------------­-- ­. . .........T---- <br /> (Draw existing and required addition on reverse side►-" <br /> I hereby certify that 1 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 /> to become subject to Workman's Compensation laws of California." <br /> Signed ... -- . - - --•----•-------- Owner <br /> By ... Z� " ------ <br /> (If other than owner]' <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY..__..... -- <br /> ---DATE a _.. .--?y.... _--------------- <br /> DIVISION OF LAND NUMBER .... --• ------. DATE.... <br /> ADDITIONAL COMMENTS.__.. _.­----------- -...----•---------------------------- ----• <br /> ----•---------------- - -------------------- <br /> -----­ <br /> ----- - ...._... - <br /> -......... ------------------- -- -- ------ ------ ---------------•................................................ <br /> ------------------------------ ...... ....... ................... .. ... -- - - . <br /> --... Date.. ./.. 13 --. <br /> ... ... _.... <br /> Final Inspection by:_....__....., - -�----- - - ---- <br /> -------. ---._ -..._. <br /> F65 21677 REV.7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />