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FOR OFFICE USE: <br /> 3V t%' 55 Z - ` FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _ <br /> ----------------------------------------------------- Permit No.. <br /> (Complete in Triplicate) �(� - - --- <br /> - - <br /> Date Issued...-4.��D'_�C J <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 Coun y Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 30 616 S SOS-. ----k_A------ ----------------------------CENSUS TRACT-------------------------- <br /> Owner's Name..-------S50ey---474?_ 1 �lPJ i!N Ri v-e° Gl�f3 ----------Phone---------------- -------------------- <br /> 30.) OOPS �1 �Sf& rV Ci �YAGZi <br /> Address - --- --- ---------------- ------- tY- -Y------------- p-------- --------------------- <br /> Contractor's Name_---_. '__� �a�tt�� 5�'�_-_____..__-----__--License #_-�6 -- ---Phone------------------^ •�1�!' <br /> --------------1 ------------ ---- - <br /> Installation will serve: Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------------------------------------- <br /> Number of living units:----- ----------Number of bedrooms_----------Garbage Grinder-------_.--Lot Size----------------------.-------------- ---------------------- <br /> Water <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--.---------If 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,) O <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth--------------------------- <br /> Capacity---------------------Type-----------------------Material--------------------------No. <br /> -----------Capacity---------------------TYPe-----------------------Material-----------------------No. Compartments------------------ --------------- Q <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line.--------------------------- <br /> LEACHING <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: Well----------------------------Foundation-----------------------------Property Line-------------------._ <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 <br /> Requirements)------1YT ------ - - --. ----- -- - -.-- --- <br /> ------- <br /> eo <br /> _ �Ie � � <br /> A_ e.4eA 4/iAa As / 1d. --E ^� <br /> ---- -------------------------------------- <br /> A &IV26y------!lee- l------- ---------- --------------------------- <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---F. /Qirrrf,viv,, `_� SdtS/.. - - Owner <br /> BY-------- ----'ll- -----------------------------------Title--------- --------------------- <br /> (If than owner) <br /> FOR ?WRTMTJ USE ONLY <br /> APPLICATION ACCEPTED BY ------------------DATE. --v�----------------- <br /> DIVISION OF LAND NUMBER--- --------- ---- DATE - <br /> ADDITIONALCOMMENTS------------------------------------------ -------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------I--------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------ -------------4------------- -------------------------------------------------------- - <br /> ---- - ------ ------ --------------- - ----- ------------------ - <br /> ---------------------------------------- - - - - - c� <br /> Final Inspection b - - - - - ------------ -------- ------------- Date T'v417= - ---- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 776 3M <br />