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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Q <br /> ------------------------------- - -- <br /> �A? wi (Complete in Triplicate) Permit No..-.. ....-� <br /> --------------- ------.......-------- <br /> Date I ssued..�q�. <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 described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION....... <br /> .--. ..-- !tAi. 0 •...... ............. ................CENSUS TRACT...--.................. <br /> Owner's Name.... . t- . -ciAt ----------- -------------- .......................................• ----Phone <br /> Address...Jj Aefy ... e 3- .... ---- ------------ r 4v.,4---------------- <br /> I - - --- - - --�-�------City..#�'>�- <br /> Contractor's Name,.C.&I l{.��1464-._-_64lA#e.. License #,36114 F4. Phone_,J&L.. -, .3S- ------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court El <br /> Motel ❑ Other-....... - ---------------------- <br /> Number of living units:.-../: _3,.:_Number of bedrooms---a..._Garbage Grindar-"o..-Aot Size-A.30-X60 ---- <br /> Water Supply: Public System and name------C4.k.1,-() 1Gk---- ---------------------------------------------- --------- _........ ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ . Clay Loam ❑ <br /> Hardpan ❑ 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 SEPTIC TANK Size....... ----------------- -Liquid Depth.------- --------------- <br /> Capacity <br /> � <br /> Type-------------- -- --Mater'sal...........................No. Compartments..---- -------------- <br /> D':stance to nearest: Well............................................Foundation............ .....- --....Prop. Line-.---- <br /> LEACHING LINE [ ] No. of Lines......... <br /> .------- ............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 [ } Depth_.............Diameter:.....:.............Number....----------.:_-------------- Rock Filled Yes ❑ No $ <br /> Water Table ;Depth- ------------- --•------ --- ......... --.....aRock Size:... ------=-------------- ---- <br /> Distance to nearest: Wall.- --=._--- ................Foundation.-:`------- ---- --......-.Prop. Line.......------------ <br /> ------.Date...... _} <br /> REPAIR/ADDITION (Prev. Sanitation-.Permit#------------------- =-- = <br /> Septic Tank (Specify Requirements)......Ad-W------c ---------. .- --.- <br /> i <br /> Disposal Field {Specify Requirements)--Co.,vo.cc/, .... ps5" ,:%�+ iisl� . <br /> -----------------• -- . ------.......----- ......-- - ------ ---------'....-- ------------------ -•-------------- ------ --- <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, I shall not employ any person in such manner as <br /> to become subject to o man's Compensation laws of California." <br /> Signed ( .. Owner <br /> By---------- ---- �' . ...._.Title °- <br /> (If other than ner) <br /> FOR PEPARTMENT USE LY <br /> APPLICATION ACCEPTED BY - ------------------- -DATE .- , .Z� ..75... <br /> DIVISION OF LAND NUMBER -------..DATE- --..... <br /> ------------------- ----- <br /> ADDITIONAL COMMENTS--- ...................... --- -•- .... ...�.. .-------------- ------------------------------ . ------.__.------ <br /> --------------------------- <br /> f <br /> ------------------------------ ------------------- ... --.........------ ......-.-.....--------------� 4 .....-.... ----- ...... <br /> -----=---- --------------=---------- ----- <br /> Final InsP66on by:.......... - ---- - Date -- � .... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT C42& ?'577 REV, 7174 3M <br />