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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> ------------------------------------------------- 2 6!G r'i a K - �� <br /> -___. This Permit Expires 1 Year'From' Date 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 described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ' GGv <br /> JOB ADDRESS/LOCATION.,____-_-6____ ���r S.gir------- u�IV Ay", ---CENSUS TRACT_________.___.____-_ <br /> -- ------- --- ---- <br /> Owner's Name---- _/V/G_11�---------Pb/,-Ie-5Phone - pp -- <br /> f - ---- - --- ----- - - <br /> Address-------------4 0--_0--_----Z'A5-Sett - - R 4 <br /> -3 )----- ° -------- - --------------- -------------------- CitY 7"YA-C� ----------------------Zi <br /> Contractor's Name-----Fl(_y� 1 _ Som 6��Sf1G .S'23't1 ZY <br /> ----------•-------------------------------License # - Phone ------- --------- ------- <br /> Installation will serve: Residence,® Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-------- ------------------------------ <br /> Number of living units:----____------Number of bedrooms---1-------Garbage Grinder_----------Lot Size-------------------------------------------______-_-_.____ <br /> Water Supply: Public System and name------------------------- --------- ---------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material-..--------- yes, type_______ _____-______- <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 [ ] Size-----------------------------------------------------------Liquid Depth--------------------------- <br /> Capacity- <br /> _-_.--_____----_-_-_--___-Capacity- �A TYPe -----'- 61trMaterial-----ea-/}lG-----No. Compartments------2=-------------------------Q <br /> Distance to nearest: Well.________._______________________________Foundation__-___. --____.__Prop. Line__ -e-1/_ <br /> LEACHING LINE [ ] No. of Lines----------------------.------Length of each line-------------------------------Total Length _._--------------------.-------- <br /> *,-e/ <br /> .__*gPc/ 'D' Box---1.------Type Filter Material_#,�*_ff___-___Depth Filter Material-----20-_-------------------------------------- ------ <br /> Distance to nearest: Well----------------------------Foundation-------- ------------Property Line___ __--------------------IL---- d <br /> SEEPAGE PIT [ ] Depth.---------------Diameter..___._._________Number-------------------------------- Rock Filled Yes ❑ No ❑� <br /> WaterTable Depth--------------------------------------------------------Rock Size------------------------------------------------ <br /> Distance to nearest: Well-----------.-------------------------------Foundation---------.----------------Prop. Line___-_______________--_____-. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date_________________________________________-_) <br /> SepticTank (Specify Requirements).----------------------- --------------------------------------------------------------------------------------------------------- ----- ---------------- <br /> Disposal Field (Specify Requirements)--------- --- --------------------------------------------------------------------------------------------------------------- <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 - Owner <br /> BY------------r✓-- - ---- --- --- = —-------------------------- ------------Title------- ------------------------------------------------------------ <br /> (If ther than owner) <br /> FOR DEPARTMENT gE ONLY <br /> APPLICATION ACCEPTED BY------ --- - --- ---------------------------DATE.-_---------� -• == <br /> DIVISION OF LAND NUMBER_---------------- __--DATE___._-__________________________ <br /> ADDITIONAL COMMENTS---------------------------- ----------------------------------------------- ------------------------------------------------------- -------------------__ <br /> -------------------------------- ------------------------------------------------------- -- ------ -------------- --------------------------------------------------------------------- <br /> ----------- ---------------------------------------------------------------------- '-------- --- --- ---- --------------- -------- ------ <br /> Final Inspection by - - ------------------------- Date <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M, <br />