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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- -•----•.--••-----.------------ . ---•- 7 9 <br /> (Complete in Triplicate) Permit No..........-...... ....? <br /> .-5 <br /> Date Issued6.- j4-77_ <br /> ••••••--••-•---•-......------.......--_...............1. 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..... t_­ ....... .�9.!l1- �Q ------- -- ---- ------- ----CEN US TRACT.------..-------- ---._._...... <br /> Owner's Name--- <br /> --�/f�. ,.-._... 1 ----- .............--...... ..........................................--.Phone <br /> Address---- BO-/..... <br /> .... ------ ------- --- - -- <br /> Contractor's Name.......-.- -, --,.�i�-. �i �:.--..-. <br /> y ..........License Phone... .. <br /> Installation will serve: Residence ❑ Apartment House❑, " Commercial.❑ Trailer}Court ❑ <br /> Motel ❑ Other-- ----...----------------------------------- <br /> Number of living units:-. ......--Number of bedrooms........Garbage Grinder.............Lot Size............�5................... ..... .. <br /> Water Supply: Public System and name____ _ --- -------------------- ___............._..-;--------Private <br /> Character of soil,to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam` Clay Loam ❑ t <br /> Hardpan ❑ Adobe ❑ Fill Material.. .... ....lf yes, type...•-----------------------_--- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.), r- <br /> NEW .INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size............1_........._.._.'------------.---------..._.Liquid Depth..---"---.--........ <br /> O <br /> Capacity............ ..........TYPe---- � Mateial- ----------------------._No. Compartments..................-................. <br /> Distance to nearest: WellFoundation------.--. . :............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-.-._..k.......... ......Prop, Line........ -- ------- <br /> r - <br /> REPAIR/ADDITION(Prev. Sanitation Permit#------------------------- - -----.----_--r.D.ate------------------ - ----------] <br /> Septic Tank (Specify Requirements)------ ------------------ '`..... .............. .................. .....-----=•------..... .............. <br /> Disposal Field [Specify Requirements]....... c� • 1 .""D`-. �JY ------ <br /> ----------------------------------------................._.:..-------------•----........-...-.+-..--------..-.-..-.-.......-----------------.-..-.-. -......................-.._...-------._.-.-------- <br /> [ u <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, Stafe 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 ,•y ,... <br /> performa'rice,,of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to becom�sub'�eict to ark 's' Comp sation laws of California." <br /> Signed...._ '- --.-- - ✓ Ownex <br /> - <br /> ------•--------------------- <br /> By........ ------ --------------- ------------------------------- ---- .....------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLYPf rt <br /> APPLICATION ACCEPTED BY---------- --- .......DATE ...... .....7.................. <br /> DIVISION OF LAND NUMBER----------------- ..-.DATE...-----------------.. --- <br /> ADDITIONAL COMMENTS-- .......... .......... -------------..._. -- --- <br /> .......................................... .. -- -- .......... <br /> Final InspEf6on by:... ----- -------------- Date.---._5_ '.7G�...... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV. 7/76 inn <br />