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FOR OFFICE USE: yip FOR OFFICE <br /> " fi II <br /> /APPLICATION FOR SANITATION PERMIT - p q <br /> ----------- -- ---- Permit No.zg~/-2/ <br /> s.., (Complete in Triplicate) <br /> -------------------------------------------------- <br /> Date Issued././.-�_.:, <br /> ...................... ............. This Permit Expires 1 Year From Date Issued ; <br /> q d <br /> Applicationis 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 corrjpliance with County Ordinance No'. 549 and existing Rules and Regulations: A _ <br /> JOB ADDRESS/LOCATION. P � V..-: --- _-- --- _--- ----CENSUS TRACT..---:-_-'__-------------- <br /> .---- <br /> Owner's Nanie. = -t. i. ------------------- -- --------------Phone. $6_r-0�� <br /> Address----- ....... - -._..c . .. �r^-'`r City. - zip--=---- <br /> - _.. <br /> v ,. / <br /> Contractor's Name -= -- ...---License #.� �f .-.... .Phone..7f4O.lP_ �oO ._.. <br /> Installation will serve: Residence Apartment House ❑ Commercial E Trailer Court ❑ <br /> Motel�_ ❑ -Garbage._------------------- ---------- <br /> $0e, <br /> Number of living units:----. _ I Number of bedrooms.-,�7 Other <br /> G <br /> . - - ge Grinder..: Lot Size------/....-: _. �..4 <br /> Water Supply: Public System and name •.--.._... -_ .................. -•-----•------------ ------------ Private <br /> Character of soil to a depth of 3;ifeet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan [ Adobe Fill Material . .... .. If yes, type,•------------------------ --.... <br /> (Plot plan,�showing.size of lot,._locati_on 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 /> /Y f. <br /> PACKAGE TREATMENT__„_[ ) SEPTIC.TANK ' Si e......- .-_.- 7�-- --------------•------- ..........---Liquid Depth. -. ------------.- --X <br /> .: Capacity- ri ... Type----2 -...Material-_ ....-No. Compartments -------- -- ----------fl <br /> Distance-to-nearest: Well-------..1 --- -- ------------------Foundation......1_Q. .--...---- -:Prop. Line- � .-..._.......-- -� <br /> LEACHING LINE- , No. of '`Lines .7 --.------.Length of.each line.......450W--------------- Tata! Length - "- -----_- <br /> II 'D' Box:....... ....Type Filter Material-.- ....Depth Filter Material.-.__./---------- -. ...-- <br /> --------Property Line <br /> Distance to nearest: Well---..L: _t.............Foundation----.�.d-�_ -- s_- ----- ----------- <br /> K <br /> p �il_7i �.....Diam-eter_..33.__-....__-Number--.....------------------------- Rock filled Yes No ❑ <br /> SEEPAGE PIT De th:: <br /> ----- Rock Size-_ / r t --------- ---WaterTble,Depth------------•-----•---•---- - ----------- <br /> Distance <br /> ---- --- <br /> Distance to nearest: Well-------j0------------------- ------Foundation----l0.'f .........Prop. Line- <br /> - <br /> i <br /> -- -- ..... <br /> REPAIR/A6DITION (—Prev-. Sanitation Permit#____. .:--- .... ........ . .. .. .........Date ----------...... . <br /> ---- <br /> -- ) <br /> Septic Tank (Specify Requirements)-- ............... :.-------- <br /> :.. . <br /> --------- ... - --- - ---- ----------- - .......... <br /> Disposal Field (Specify Recluirer",merits)------ --------•------ - <br /> -•--•----- .............. -- .--.'---------------- •-------- ....... .... -------:--- - ------ ---- - <br /> -------- ....-. <br /> ...---- ----- <br /> --------------- -- -- ---------- -------- - - <br /> ii. . (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 i Rules and Regulations of the San Joaquin Local Health District, dome 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 Workman's Compensation laws of California." -_; <br /> Signed_..: ... ------- -•-- ..._.Owner <br /> ---`-� J. <br /> ........ Title-.:... ..... <br /> By-------------- .... '-...... <br /> ! f other than owner) <br /> it <br /> FOR DEPARTMENT USE ONLY ' <br /> I ` DATE sf-�l`-��'.__.... <br /> i APPLICATION ACCEPTED BY-..I...�. .. . ..' --.. - - <br /> DIVISION,OF LAND NUMBER..a.---- .._._. -----..... ------- <br /> ADDITIONAL <br /> DATE__...----... <br /> ADDITIONAL COMMENTS--..--.-il---..-...._. -------- ----- <br /> -i'- . <br /> --- . ------- -- - -.--.............. ....._ <br /> - .-_... ---------- --------- -------- -------- <br /> 4 --. ­1------------- ---- --- --- ............... ....... ........ ........ ...... ....... <br /> --------------------- - -----_------ ..................... <br /> . .._ _ /�, <br /> Final inspection b pJ. ..- . ------ ...Date .rl . <br /> ' Y = <br /> F <br /> EH 13 24 ` SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76.3M <br />