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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> This Permit Expires 1 Year From Date Issued 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. 3 Sf L.......l 44�r4y �..� I ...-------- - - ---------•--------....CENSUS TRACT....................... { <br /> Owner's Name..._ ff.. -...... <br /> Phone-..5� 3.-.. a7.o_ .--.. <br /> Address1.._E- .�P -----Cit <br /> Contractor's Name......... k'/S-f 50 License #- S <br /> -1-3 V3 Phone.----`7.6 ....... ........ <br /> Installation will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other ---- -- - - ---------- <br /> Number of d <br /> Number of b <br /> N <br /> - <br /> . <br /> livingN! its:_r. ..,/----- - uerooms--.Z--,.Garbo a Grinder,--... ..._Lot Size.............��. .. - <br /> r _ _ y. g ,, X --------- <br /> Water Supply: Public System and name..........C! L_ (�R�F�/� -Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material------- ..-.If yes, type..................... - <br /> -----...--- lin <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----------------- <br /> ......Mat`erial-T ----------No. Compartments......:.:... <br /> 77 Distance to-nearest: Well----------------------.._.............-------Foundation............ .------......Prop. Line................... <br /> LEACHING LINE [ J No: of,'Lines-----------------------------Length of each line------.----------------------Total Length .....----......---.--.---.-------...-:. <br /> 'D' Box- .......Type Filter Material........ ...........Depth Filter,Material..............................-.....-----_-_-------.---------- <br /> ,,.,_•,,Distanceto-nearest: Well...........1.b' -- -----.Foundation-------.....................Property Line-.-------•-------------------------- <br /> SEEPAGE PIT [ ] Depth, -.. .......Diameter.--------------_._.Number.....-..-------...._._--_--... Rock Filled Yes ❑ No ❑ <br /> --- _. <br /> Water=Table Depth. -------------------------------..Rock Size------------- --- - •-------.-----=----•-....._ <br /> Distance to nearest: Well.-'-----." ". ........................T.Foundation------------..............Prop. Line............................ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...`_ - Q ,��'...--°-- I-.--------- - Date-------A/aci:. -.----_----} <br /> Septic Tank (Specify Requir`ementsl--�/�/ 1 ------- <br /> Disposal <br /> --_l-Disposal Field (Specify Requiremerits).6 _7,xe.../1/T�...&_i'SLS7r_416- 4�'Aj-)6-F,. - <br /> ------------------------------------------ <br /> ---- <br /> k <br /> ------------------------------ --------- ------ - ---------------- -- I <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 certifythat in the " <br /> 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------------- -. - ----- �C.------ -------------•------...------ ..-Title.. .7 G ®lC......- ------ <br /> (If other than owner) <br /> F DWARTMEbK USE ONLY r <br /> APPLICATION ACCEPTED BY........... . . cW �^ DATE ..��~..79................. <br /> DIVISION OF LAND NUMBER...---- ... DATE------------------------------- --- ------------ <br /> ADDITIONAL COMMENTS .................... <br /> -------------------------------------- ----------------- <br /> ------------------------- ------------ ---- ..------------•-•.................................-•- --------------.--------------- - --- -- --•-•- - ------------- .... - ------ <br /> -----------­----tr----------- <br /> ----- <br /> -- -------...._t-------•--- ----- - <br /> Final Inspecflon by:---. Date.- - ----------------------------- <br /> ------------------------ ••----------------------------------... . 3 <br /> EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f&S 21677 REV. 7176 3M <br />