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FOR OFFICE USE: FOR OFFICE~ USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit N . . <br /> _ ... <br /> . ........... .....•----- .-------------...--.---... o' ...... .... . <br /> .•....... ..... . ...... This Permit Expires 1 Year From Date Issued Date Issued.5.-�/5.:77.7 <br /> Applicotion is hereby made to the San Joaquin Local Health District for a permit to co truct and�nll the work herein described. <br /> This application is made ' c la n d' ti les and Regulations: <br /> JOB ADDRESS/LOCA. ON L. W ' _. L .. --CENSUS TRACT.. I�L <br /> ,�/ <br /> Owner's Name.... Q&Z ..:31 ., � --.. Phoh .ate �3..�'.��7 <br /> Address..._1/�'yV- .� -------------------- <br /> /► .. <br /> �' _.. / -._. 1v------- ........-- .. ----A rf ......zip 9.� ....... <br /> Contractor's Name.... yt - License #_-- <br /> __----- .- .- . G?3�/� �$. j�Phone�j0. �.2�-- ----- <br /> Installation <br /> - -Installation will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ � � <br /> Motel ❑ Other....... ----------------- ^� <br /> Number of living units:. .--- .`----_Number of bedroom ---Garbage Grinder. Lot Size...-- <br /> Water Supply: Public System and ^ �. -- ................. ----_------------_.-Private <br /> Character of soil to a depth of 3 feet: Sand EDDSilty]- Clay.El . .Peat.❑. Sandy Loam Clay Loam El <br /> �. <br /> Hardpan Adobe ❑ Fill Material.. ----_.If yes, type........................... � <br /> (Plot plan, showing size of lot, location of'syst&r ih relation to wells, buildings, etc. must be placed on reverse side.) -5 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGETREATMENT [,] SEPTIC TANK [ SS,ize,� o - .-.-------- Liquid Depth.---- ------..--.-_- <br /> Ca acit /,2�y ype. -!-W�1 (fl`�I P �" r� <br /> P Y rs�a�- - Material- - _ --�.'--,-...No. Coin artments..-- .-----.------- 1 <br /> /j '� {4). .t.. ...Prop. Line---,/� ......... <br /> - Distance to nearest: Well -� ._ ......._-...._ ___-foundation-.-- <br /> LEACHING LINE No. of Lines r <br /> ,l'y-r �.---••-----�-•-- Length of each li e.----�,�.,�-� - -- - Total Length .. 0-0--�---�-.---...--.-.---.- <br /> ' s� <br /> D' Box,./. - ...Type Filter Materia Q Depth Filter Material..1�---- ----------------_-..-.... ------------------- <br /> Distance <br /> . . --------.----- <br /> Distance to nearest: Well..,_ ?��!f7= <br /> ....Foundation.--��/ --_---- -Property Line-.�(°�./�................ <br /> SEEPAGE PIT �]- Depth_. . . _....Diameter--. .........Number.._._............. �. Rock Filled Yes No ❑ <br /> Water Table Depth.-----------V-0-f -------------------n -.-.Rock-Size' L <br /> �.v Distance to nearest: Well--------o?AP _.........Foundation_f-9 15f..........Prop, Line-14W___--- -. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ---------------Date---------------. .......---------_- -.--.} <br /> Septic Tank (Specify Requirements)._... ....._ ----------------------------------------.......--_-.--............ <br /> Disposal Field (Specify Requirements)_- ........ ----- <br /> f -------------------------- ........................................ ----.........................I-------- ------------ --------- --- ------------- ----------- ------------- <br /> ----------- --------- ----------`- ----------- <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 certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Sig _ _.... -----Owner <br /> By.................... ...... ------Title- ------------------ ----..-- ----------...--------- - - <br /> (If other than owner) <br /> FO EPAR MENT USE ONLY <br /> APPLICATION ACCEPTED BY......... ... .. ..�.- -.--------.1---------.-.- -DATE ....�.�trj�'+ . .-.-----.. <br /> - ---------- --------- <br /> DIVISION OF LAND NUMBER-------- .......................-......DATE ............ . ........--- <br /> ADDITIONAL COMMENTS. . ....................... ....-.--.-------.....-----.-.--..-- -- ----- <br /> ------------------ <br /> - --•-------- -------------- -- ----- •---•------------ - - ------------ <br /> Final Inspection b Date. .. <br /> y: f -- . r.��z ------------------------------- -------- - <br /> {" 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT <br /> F&5 21677 REV. 7/76 3M <br />