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FOR OFFICE USE. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.... 7.. <br /> i ----------•-••---------- .... .............. <br /> Date Issued-L�.: ::.?./. <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 />}ifJOB ADDRESS/LOC,AeT^.C_KI" I1?....... S'......... ^ --......CENSUS TRACT.-_--------- . .. <br /> . .CLAU <br /> ame.--- - ------- <br /> . <br /> Owner's Ne . R ._ � �C [ P . 3 - ,2c.)�u _ ......- .... . <br /> Address---- ""5��� CitY--I)An?�e `` 71P---'�-�---- ' --------- <br /> Contractor's Name"- ctf� 6t li_ License #._�y '. -_- .Phone---------------------------------- <br /> Installation willE`serve: i ; Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ <br />' ' I Motel Other------ - -- ----- n -----------------L--- 4;bNumber of livingunits:..::-.----•_----Numbr of bedrooms...-...Garbage Grinder_ Size.......... --- <br /> ---.._---.--------.... <br /> ...F - -. <br /> - <br /> , <br /> F Water Supply: Public System and name...._. ------- ---------.---------------------..........-............---------Private <br /> BI— <br /> Character of soil to a depth of 3 feet: f Sand9110*�Silt❑ Clay.❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> J;Ia�rdpan ❑ Adobe ❑ Fill Maternal.. .... ... If yes, type-------------------------- ---- <br /> (Plot plan,`sliovvT6d 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,( Yi r <br />' PACKAGE TREATMENT <br /> ] � SEPTIC TANK ( ] Size...... -- -----k-- ----------------- -----------Liquid Depth...........Z' ............ <br /> Capacity... - ------Type.. RCfA `' Material.. _..----No. Compartments.----...'�--------------- <br /> T <br /> f Distance to nearest: Well .. . ._....Prop. Line.... . ..�__........ <br /> • .��,. � t -�----- - ---...Foundation---------- - ---- � -- <br /> LEACHING LINE-., [ ] No, of Lines ---------------------------Length of each line:----------_....._------..._. Total Length .. -------------- <br /> 'D. Box-.......:...Type Filter Material....................Depth Filter Material....:.-.-.....---...-.---...---•---•--•- ..---....--.--.--...-.. <br /> •Distdnc5 to nearest: Well--- y_ Foundation`--�- = °:-------------Property Line-------------................ ... <br /> SEEPAGE.PITIMI Depth .,_:"..- -.. -Diameter-.---:--_---------Number.....--------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depths Rock Size— <br /> --------------- --------- <br /> ... . Foundation Distance to nearest: Well---------- -- ------ - ----� " "---- - on................ Prop. Line----`-... ................ <br /> ..� �.. � .gate.-..< <br /> REPAIR%ADDITION (Prev. Sanitation Permit#.................................. .............. ..•-------..".-�--- - .-.------.---I <br /> E F <br /> Septic Tank (Specify Requirements)--....-.� .`���1--_.-- '- L-Trd� �Q .- --- .. .... <br /> Dis oral Field (Specify Re uirements�.....�..'.�.�PM- ------------------------�.-._�v. __ K17/ �--- - ------------ ... <br /> PP Y q Y ------------------------------ --------------- <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`iA m 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: T! <br /> "I certify that"in"the performance f the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to-Workman' ompensotiorl laws of California." <br /> Signed- ------------------------ - --------Owner <br /> By......- :_�.- --•-------------- Title ................. -- ------------------ -" - ----------- --- <br /> (If other an owner) <br /> FO DEPART ENT USE,ONLY- � <br /> rk <br /> 1 <br /> APPLICATION ACCEPTED BY.<..-.-. 0'`� .....DATE -.....-... 7. .......... <br /> DIVISION OF LAND NUMBER .............. .....-- ------------------------ `. DATE.---' --- -.. :---...--- <br /> ADDITIONAL .COMMENTS-,--7--2� °" ..r /z"�r= � ....... .,�. <br /> ................... <br /> ✓ ,:� .. ............ ....... <br /> /� //�/�� 7 i - --- - ..... .............................. <br /> Final Inspection by:- -------.. . . . -------------------------------------- ------------------- ------- <br /> Date--- <br /> ._ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8S 21677 REV. 7/76 3M <br /> i <br />