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: ' <br /> i APPLICATION FOR SANITATION PERMIT FOR OFFICE USE <br /> -- - _ <br /> ---------FOR OFFICE USE;- -- {Complete in Triplicate) Permit No.�.7-`_Z16 g <br /> This Permit Expires 1 Year From Date Issued Date lssued,5.-/� <br /> Lpplication is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> rl <br /> application is made in compliance with County Ordinance No. 5A9 and existing Rules and Regulations: <br /> ADDRESS/LOCATION.---.... - _.. _ .�``........... ........ vl-12.L. �....----------------- .... -.CENSUS TRACT- _....... <br /> ner's Name.._ .- .J � � . ..1.-i. .f yt 5- 14_..-... - ..Phone.... ��-- � -- _.-. <br /> .. > <br /> dress. -a f" -- ... Ci <br /> - �------- -�-----.. - ... �- tY-- --- -�?'r. . ..._�...... ...............zip---�..�33� -.. <br /> contractor's Name........ --- ......... ......... .... .........License #- ------- - -------- .....Phone.----------- --------.. <br /> tallation will serve: Residence ❑ Apartment House ❑ Commercial E] Trailer" <br /> Court ❑ <br /> t Morel Other..... <br /> rJrn ber of living units:.....)..._--.--Number of bedrooms...../—..Garbage Grinder-..------.__Lot Size...._...�.r`r.-s..........ter Supply: Public System and name-------------------------- ----- ...-............................... ............ ................................................Private - <br /> ,horacter of soil to a depth of 3 feet: Sand ❑ Silt❑ . Clay ❑ Peat ❑ Sandy Loam, Clay Loam ❑ <br /> For pon ❑ Adobe ❑ Fill Material— .... ....If yes, type................................ <br /> -rot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) - <br /> INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> [ZKAGE TREATMENT ( ] SEPTIC TANK N Size------- -------------------------------.-------- --- Liquid Depth.---.--.......---.._....--.F <br /> Capacity. - 1�.4FII.-TYPe- r .. _.Matevial-- rPY <br /> ,.:No. Compartments-----.:- .................... <br /> Distance to nearest: Well_------- ................. .........Foundation-----ZO. . ._...........Prop. Line---,/c;�&L3-.--.--...-.-- <br /> [CHING LINE No. of Lines .. ...._2--..............Length of each line ------7.0................ Total Length .......kQ--------------- <br /> 'DBox_. T.. Type Filter Material.... ' ..-. Depth Filter Material--------------- .s...__.-_-------------------------------- <br /> Distance to nearest: Well---- --- ......_Foundation------°,�1-f�--------.__Property Line.-- �`._ v.�..,. <br /> =EPAGE PIT [ ] Depth..... ...... ...Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth--------------- - ------ ---------.Rock Size...-----.............-- ------­ <br /> F_ <br /> Distance to nearest: Well..............._- <br /> ------------------ ------Foundation._...----- ...._...Prop. Line-- - -... ------...._..... <br /> AIR/ADDITION (Prev, Sanitation Permit#................. - --.............Date--..-------•---..--------.--.-.----.--..--_..) <br /> 'tic Tank (Specify Requirements)............. ....... ---------------------- --------- -------_---------_------- ---------- <br /> lisposal Field (Specify Requirements)------ ------- -------.._..----- --------( ---- -----------------......- - - ---- <br /> ( ---------------- -------------- <br /> ........ <br /> ­­------------ <br /> -------------- ...... --------------- .....................­­­-- ----­--------------------------------------- --------------------------- .......... <br /> {Draw existing and required addition on reverse side) <br /> reby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> _finances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> gnature certifies the following: <br /> Fertify that in the performance of the work for which thin permit is issued, I shall not employ any person in such manner as <br /> become subject to Workman's Compensation laws of California." <br /> rned. t{J .... E�',7?=r'7 _ -------- ----- --Owner <br /> ----------------------­------ - -------------------- . Title--- . ----------.---- ---- -- <br /> (If other than owner) <br /> WR DEPARTMENT USE ONtY <br /> F;-LICATION ACCEPTED BY-----. .. . 1 � ,f�����_...:----- - ---------- <br /> ---- - ---------------- --- -...DATE ...... � � �...�....--- <br /> IVI5{ON OF LAND NUMBER_............. . DATE..------------- --- -------- - <br /> FITIONALCOMMENTS.... ....._.... ----------------- ----------------------- -------------------- -------- .... . . ........-. .. <br /> ----- — ........... ......... ............... . .......................... - --..... ........ <br /> -------- .................... -------- ...... -- <br /> ---------- ----------------------------- <br /> 1 al Inspection b yr(`Y'�L '� <br /> 1 i y:.. - :....Date. - . --.. --- <br /> 1 is 74 SAN JOAQU.IN LOCAL HEALTH DISTRICT ,�;!�% s'' r8S 21677 REV. 7/76 3M <br />