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FOR.OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------•-----------.�:._4.. -- --- ----.... --- ► I. 1k . ., d 'e 29 �4 , <br /> 1 meq' P--mit No------------------ --- <br /> (Cort4plete !ri`Triplicate! <br /> --k <br /> VJ <br /> at � <br /> ------------------- <br /> '� -��—�7 <br /> De Issued................... <br /> k •................................................ .. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District fora permit to construct and.install the work herein described. <br /> This application is made in compliance with County Or nonce No. 549 and existing Rules an4ez I ions: <br /> JOB ADDRESS/LOCATION....... ----..CENSUS TRACT................. <br /> -- - -- ---- -------- -...-•--- - --- -....-.....------ ------- <br /> Owner's Name - - ��-.--- � � ........... .......... .......................... Phone.--- ...----------------...-.........- <br /> Address---------- •. Zi <br /> .. ...City .� P--- <br /> --- <br /> Contractor's Name--- <br /> License #.J�0 / Phone_Y.. � `� <br /> Installation will serve: essidenceAtel <br /> Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> ❑ Other-------------------- <br /> -- - •----------------- <br /> Number <br /> -•------- ----- ll . <br /> Nu g i / g - --L .. f.. ..- ------ - ------- <br /> tuber of living units: �r ---- - --------- ------ <br /> - Number of bedrooms__-_ __....Gar Garbage Grinder Size <br /> Water Supply: Public System and name--- -- ---_ . ---.;--------Private-f <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt 0 Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material....... ....If yes, type-------------------------- ----- <br /> (Plot plan, showing size of lot, location of system 1n 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 avai9alale within 200 feet,] \ <br /> PACKAGE TREATMENT '[ ] SEPTIC.-TANK }'--.S1ze. ,�- <br /> �... - .' Liquid Depth---- ----- <br /> s <br /> CapacityVOP.----Type .....-.._Mat.er.ial— - ..._.:--:No. '' o6mpartments - --------_--- <br /> I-V <br /> 11 <br /> Distance to nearest:,Wei I-.-..! �- _ __ _ .Foundation.--/Vi-_-.. --..-.Prop. Line..................... <br /> r � <br />! LEACHING LINE [ ] N6of•Lines ..._ rr <br /> Length of each line T,Loal L'e igTh f <br /> D',Bo '`Type Filter Materi ._ -., $�Depth Filter Mat ---------------------------........--__..... <br /> . . <br /> Distant to nearest: Well Foundatio ----------------------------Propert Line...... <br /> SEEPAGE{PIT�'[ ] Depth-`- t..Diameter.-- - -....--.Number --- - -------------------- R Filled Yes No`� <br /> Wciter Table Depth......- __Rock Size-.. <br /> Distance to nearest: Well---------------- ---- --------------------Foundation------------.-.......]..---Pro . Line......_---------....... <br /> REPAIR/ADDITION '(Prev. Sanitation Permit#................ ................------------......Date-..-. ,_.. .......... ---------- ---1 �v <br /> Septic Tank (Specify Requirements)---------- ------- ------ -- -------- ----------- --- --------------------- ----- ---�. .. .... ----- -------- - -------------------------- <br /> . <br /> Disposal Field (specify Requirements).;.. . ..... -- ------------- a <br /> t <br /> --------------------- .......................... ------ -------------------------- --------- .....--------..--------------- -- .... <br /> -- -- - ----- <br /> -----•------•-- ----------- ------------------------------ - ------- <br /> i (Dra existing and re uir d a dition on reverse side) <br /> I hereby certify that I have prepared this pplication and that th ork will be done in ccordance with San Joaquin County <br /> Ordinances, State Laws, and 'Rules and Regulations of the San Joaquin local H 'District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the w k for which t s issyed, I shall not employ any person in such manner as <br /> to become subject to Workman's mpensat laws of Califor ia:' <br /> Signed- <br /> - - ---- ------- � ... ------ �-------�------------ ------ -Owner <br /> BY ...... .... .... ...... �. 1 Title = - <br /> (If other than owner) <br /> t F DEPART T VX ONLY <br /> APPLICATION ACCEPTED BY......... . ... DATE --.-.-- .-- --f.o. -.77 <br /> DIVISION OF LAND NUMBER........... . ..................DATE.......:: _._ -- ...... <br /> ADDITIONALCOMMENTS..--......... ......................------------------------------- ----------------- ........... ----.-------..-.-.. ................-... I------------ <br /> -------------------------------------- ---------------------------- -----------.------ <br /> ------------------------------------------------------------' - ----------------------'-- ------------ <br /> Final lnspecTion"b'-y- <br /> _- --........Date----_--------•--------- .....---- <br />[ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />