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FOR OFFICE USE: <br /> FOR OFFICE USE: / <br /> APPLICATION FOR SANITATION PERMIT / <br /> (Complete in Triplicate) . <br /> Permit No.;7g�= -F-f <br /> ---------------- <br /> Date issued____ <br /> -------_-_--------------------------------------- ---- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local H`6alth 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 Ru4"a <br /> es and Regulations: <br /> /4) G C1�, � �,--5, ------.CENSUS TRACT-------------------------------- <br /> . <br /> JOB ADDRESS/LOCATION - - -/------ ------ --- ------- --- ------- - ---- �---- <br /> Owner's Name. ------ �G1• Phone <br /> --------- ✓- � ' """ Cid` '� P <br /> Address- ---- ------------------ f� Zi / <br /> Contractor's Name--------------- - - '�-'-----cam-----'-----------------License #-a�- - - ---Phone-��_���-�-_�!-... <br /> Installation will serve: Residence �artment House ❑ Commercial ❑ Trailer Court [I <br /> Motel ❑ Other--------------------------- --- ----------- <br /> Number of living units:-.-----/-------Number of bedrooms---2--Garbage Grinder`'L�---Lot Size____-�I-----/ we�1.�-----•----------------- <br /> Water Supply: Public System and name- -------------------------------- ----------------------------------------------------------- ---- ----------------------Private* <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt Clay F] Peat❑ Sandy Loom ❑_ Clay.Loam E]Hardpan ❑ Adobe Fill Material_/I, U_-If yes, type-------------------------------- <br /> (Plot <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: (Nod septic tank or seepage pit permitted if public sewer is available within 200 feet,) 0 <br /> PACKAGE TREATMENT C ] - SEPTIC TANK [ ] Size----- ---- ---------- -------------------------------Liquid Depth---------------------------� <br /> Capacity--------------------TYPe--- -------------------Material--- ----------`-----------No. Compartments--------------------------------- <br /> Distance to nearest: Well---------- <br /> ----------------------------------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: Wei ls;__----------------------Foundation------------.----------------Praperty Line----------------------------------- <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------,_----------Number-------------------------------- _._ Rock Filler) Yes ❑ No ❑ <br /> WaterTable Depth---- --------------------------------------------------- Rock Size------------------------------------------------ <br /> I _ - <br /> Distance to nearest: Well---- ------------------_-----..----.--.--.Foundation.-.--- ----:-..Prop. Line----------------------------- <br /> REPAIR/ADDITION <br /> -_----------__._.REPAIR/ADDITION (Prey. Sanitation Permit#---------- --- -----------------------------------Date ) <br /> Septic Tank (Specify Requirements)------------- --------------------- <br /> Disposal Field (Specify Requirements)---------------------- --- ----- ------------------------ <br /> r <br /> --------------------- ---------------------------------------------------------------------------------------- <br /> --------------------------------- --------------------------------------------------------- -- <br /> (Draw existing and required addition on reverse side) <br /> 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 emploZ any person in such manner as <br /> to become subject Workma Co pe <br /> Signed--------------- -- <br /> nsation laws of California. <br /> l / . - ---------------------------Owner <br /> -,�. -� <br /> By------------------- --- ---------- - ----_ -- ----------------------------- --- --- --Title------ ---- <br /> If other than owner) <br /> OR EPART NT U ONLY <br /> APPLICATION ACCEPTED BY--------- ---- . - DATE.------- . 4� ----------------------- <br /> DIVISION OF LAND NUMBER - DATE-------- - ----- ----------- <br /> ADDITIONAL COMMENTS---- --------------------------------- -- ------------------------------ ----- --------------------- �` <br /> -------------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------ -- --------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> - ----------------------------------------- - ---- --------------------------------- <br /> --------- <br /> --- -...---------- <br /> --------------------------------------------- -------- -- <br /> Final Inspection by:-- - ---- Date �� = <br /> EH 13 24 _ SAN JOAQUIN LOCAL HEALTH DISTRICT F&s sia» ¢f1/�{7/76 3M <br />