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PLICATION FOR SANITATION PERAW <br /> ...................•--............_........._ <br /> (Complete In Triplicate) Permit No. .77�.73__. <br /> This Permit Expires 1 Year From Dat*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 <br /> described. This application is made incompliancewith County Ordinance No. 544 and existing Rules and Regulations: <br /> .,/. <br /> JOB ADDRESS/LOCATION ........,cam - a0......./--Q-`- -- --.....MO. <br /> ,/.. ® .............CENSUS TRACT .......................... <br /> Owner's Name (1 f�� l /tyone ..... ..............•-- ----------- <br /> Address ... . . t'Lt.Q .. ?..d 2r.Ci ^ / D o <br /> Contractor's Name ---...S.. ..._.F..............................................................License #s-A—1 3 .. Phone <br /> Installation will serve: Residence Apartment House Commercial❑Trailer Court 0 <br /> Motel ❑Other........ .4?Y....G:ti! '.... 1 C c I <br /> Number of living units:-........... Number of bedrooms ...3....Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name ........................................................._........_..........................................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand D Silt❑ Clay 0 0eat❑ Sandy Loam Q Clay Loam ❑ <br /> Hardpan ❑ Adobe 0 Fill Material ............If yes,type............... ............ <br /> Q <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 I •,X/Ste/ ...... ✓ ............. Liquid Depth .__CJ ...... <br /> Capacity <br /> t <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 ............................................ s . <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ <br /> GSEirRAGE-PIT [ l Depth --- ------------_- Diameter ................ Number ............................ Rock Filled Yes ❑ No 0 <br /> M Water Table Depth ...Rock Size <br /> gx Distance to nearest: Well ........................................Foundation -------------------- Prop. line ................... <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -.--..--...........:..--------S ............. Date .................................. <br /> Septic Tank (Specify Requirements) ........................... ................:............................,......--................ .1...... <br /> Disposal Field (Specify Requirements) . .. ..-.. ..... ........... r.�......._. <br /> ............-...........- ------ <br /> .................... ....... ........ --------_--............................................_............................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health.District. Home owner or licen- <br /> sed agents 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 <br /> as to become nssu'bjject to W r mate's mpensation laws of California." <br /> Signed �C� -xX�" . <br /> ©..--- - � - ---- -----•-•----...-----•--•-•-----....._ _ Owner <br /> ----- --------•-•-•-----•---- •-•---••--• Title ..... C ".c'........_................_......._._...-- --- <br /> (If other than owner) <br /> A FOR DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY - i DATE ..� ^-...., . '" <br /> ...................... ......... .. ... ........:.... <br /> BUILDING PERMIT ISSUED - DATE <br /> ADDITIONAL COMMENTS _._ .._ ....._ ...... . ..................•-............. ..._....--.. _....._. <br /> __,....... ---- ------- ---- ... .-------•............_..................-.........--- ........ _ <br /> Final Inspection by: ._..--..-... ........Date .. <br /> __..-_.. . .. ............ . . . ....•-._.........-.................._........... <br /> EH 13 21a 1-Gf3 Rev, 5i . .. 11 <br /> ............ <br /> SAN JOAQUI LOCAL HEALTH DISTRICT 8/74 3M <br /> I <br />