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FOR OFFICE USE: ro 0 U Co "� 1 FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _ <br /> (Complete in Triplicate) Permit No .� <br /> Date Issued-V ------.-- <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.-�QT. iIVXvCX CCvG---------..CENSUS TRACT...._-------------_--_--- - <br /> ------------- <br /> Owner's Name.-_ . pON......13.d.4�s_. ......._. .............. .... --------------.Phone --- --- -- ----------- - <br /> Address............3OV. 0 V . --.-)J-A, Ive ----- ------ --------- - -- -------- -----city.- 7YR Zip--_----------- -------- <br /> N... - Phone_.. . : . -- - - <br /> Contractor's Name.----�:.kVP.*V._ �c -------- -....--.License #_..���-596- --- >R3' %,T/ <br /> Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------._ <br /> Number of living units:-----I........Number of bedrooms......L._ Garbage Grinder------------Lot Size-_.__..__._... .._._._._ --------.:_-_-..._. <br /> Water Supply: Public System and name_ ----.----.s'.J' X _5----------- ___________________Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material.. _-._----If yes, type....................... <br /> ...._. . <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 [ j SEPTIC TANK [ j Size ............. ..........................................--Liquid Depth-------...__.__..----_� <br /> Capacity.«Q.0...-•----Type-A-5 G',n�T... Material_.. G1!e...-- ....No. Compartments.......i�K•------ <br /> Distance to nearest: Well-------.........___ ------ ..___._.....Foundation_-. . ...- Prop. Line_:5...._.........___-.- <br /> LEACHING LINE [ ] No. of Lines ._.....__.Length of each line.....................__..._. Total Length --'zQ_--X__------ -... <br /> �0,�rc7 /fid '13 Box_._/.._ . Type Filter Material.Aa.c_k.......Depth Filter Material_.__.. ..__....._..........................--------- <br /> Distance•to nearest: Well.........................:-.Foundation----- _..._. --------Property Line..-- <br /> SEEPAGE PIT [ j Depth._ ------ .----Diameter__------------------Number_............................. Rock Filled Yes ❑ No❑ <br /> Water Table Depth-------------------- --------- -- ..__-- --•-------.Rock Size-- -- ._----------------------------------- <br /> Distance <br /> - ---Distance to nearest: Well_... ---------- ---------------------_-Foundation------------.__ .........Prop. Line....._.......... <br /> .._...__--- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...'--------------------------------- ---------......Date...........:----------------------- ---------) <br /> Septic Tank (Specify Requirements)_.____................. <br /> Disposal Field (Specify Requirements)-- --------------•--•- _- ---- --------------- .........................___--------------- ------------- <br /> r� <br /> -............. ----------... ........Z_. <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 Workman's Compensation laws of California." <br /> Signed....4�- —74.r" �..Sa/`/ ------ _Owner <br /> By--------- - --- --- ----------- ---- ••. -------- ----......_---.......-- ---- --------------_-- Title --- <br /> other than owner) <br /> F DEIZAR MENT USE ONLY <br /> APPLICATION ACCEPTED BY_-_ _.... __...DATE .- _...:� ..-.-. �----..--- <br /> DIVISIONOF LAND NUMBER.-- ------------------------------- ----------------------------------------DATE..._.---DATE-.......__..--- - ---- ------- ----- <br /> ADDITIONAL COMMENTS._.................. ..... .... -- -- <br /> ------------------- - ------ -------- ----- -­------------ ....................---- --------...-----... .................... ------------------ --- -_........ . -- ..._ ... <br /> ------------------ ----- ----------------------- --------- - -------- ......... <br /> - G --- - <br /> c ---- <br /> -r <br /> - - <br /> --------•------------------ ------ ............. <br /> Final Inspe <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT C-1�S 21677 REV. 7/76 3M <br />