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• FOR OFFICE USE. FOR OFFICE USE: <br />IDOAPPLICATION FOR SANITATION PERMIT <br />...........-•---•--------------• - - -............. Permit No......:._...1.. <br />(Complete in Triplicate) <br />Date Issued....'. %..%f <br />......................................................... 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 describec <br />This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br />JOB ADDRESS/LOCATION..... ........................................... ........................................`'. .CENSUS TRACT............---............... <br />Owner's Nome............ c -c:-, Y �.......1..l�,ew+.t.Ca.�................................................ Phone.............................---.... <br />Addresses 1 E---a.�aG Ci.t''4? zi <br />tY... ....- . �... P <br />Contractor's Name. -. ?''1'".).rz ...... ...-> ............ License #. .� i'��- .Phone.4t-14-1:7-941 d <br />Installation will serve: Residence ❑ Apartment House ❑ Commercials] Trailer Court ❑ <br />Motel❑ Other ..................................... ......... <br />Number of living units: ------ .........Number of bedrooms ............ Garbage Grinder ............ Lot Size ................. ................................. ...... <br />Water Supply: Public System and name .................................................................................................................................... Private [ <br />Character of soil to a depth of 3 feet: Sand Silt ❑ Clay ❑ Peat ❑ Sandy Loam C3 Clay Loam F1Hardpan ❑ Adobe Fill Material .. .... .... If yes, type .............................. <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 [ I SEPTIC TANK [ I Size........................................................... Liquid Depth......................... <br />Capacity ..................... Type ....................... Material .......................... No. Compartments ................................. <br />Distance to nearest: Well ........................................... Foundation........................ Prop. Line......................... <br />LEACHING LINE [) No. of Lines ......... ...................Length of each line .............................. Total Length ....................................... <br />'D' Box ............ Type Filter Material ....................Depth Filter Material ................................. ............................. <br />Distance to nearest: Well ............................Foundation............................ Property Line ................................. <br />SEEPAGE PIT (J Depth ................ Diameter ..................... Number................................ Rock Filled Yes ❑ No [ <br />WaterTable Depth ......................................................... Rock Size ................................................ <br />Distance to nearest: Well ............................................ Foundation .......................... Prop. Line .......................... <br />REPAIR/ADDITION (Prev. Sanitation Permit # ................................... ............... Date ---------------------------------------------- ) <br />SepticTank (Specify Requirements) --.......-......................................--•--.........----•-----...... j-•----...-----..........----•-•--.............•--•--................... <br />Disposal Field (Specify Requirements)....�_Oc%=D ...4. ............ �r_.k....... ► ............ C�- -• •-••••••-••••••'- <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 Count <br />Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agent <br />signature certifies the following: <br />"I certify tha i the performance of the work for which this permit is issued, I shall not employ any person in such manner a <br />to bec a ubject to Workman's Compensation laws of California." <br />Signed....... .... Owner <br />By ....... ......................... Q (��rl/--.....---........Title. .. <br />�fr 1 <br />th r than owner) <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY ........... .. v <br />DIVISION OF LAND NUMBER....., .............. ....._----------------•----..............,.. . <br />ADDIT NAL COMMENT .._.r1.i�... C.>.....,....rz.� <br />'�.1.�.4.►-..,. �.r �.x�„�.�,1. y......-22.../&- - -ems .. <br />.......... ................a.--- .......------ . --.... --- -----.--•---...•-----•.----........./................ <br />...----.-•.... ----------------............................... ............... <br />DATE ....... 3—._-.3/:'.-c% ............. <br />...............DATE... . <br />.--------- <br />----... <br />D�........ <br />Final Inspection by:. ..... ......................................• ate <br />........ <br />_ .. <br />EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 Rev. 7/76 <br />