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FOR OFFICE USE: . FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> -------- -- . <br /> ------..--. .-- <br /> (Complete in Triplicate) Permit No,2$.-7�21.aZ <br /> ------------------------------- ------------------- Date IssuedA;?.4---28 <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.----3.% .9...........J.q. -------------- --------------------------CENSUS TRACT.....-•------ --- --------- <br /> Owner's Name.. ....0!Fq -TT!'..... --.,l3ra�F----- ---------- - ------- ------- Phone.-- ------­----- ------------- <br /> Address---------------..-- ................----..... ---- --.--.--- . . City--]'ria Gy--•.. --------- .........zip----- <br /> Contractor's Name--- f= ` ..-.License #../.. _6."-...... ._Phone------------------------ <br /> y.�.Th a � -s �/ <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other............ ...--- - ---- ---.......... <br /> Number of living units:.......L....-.Number of bedrooms----:�F....Garbage Grinder--------....Lot Size....--` -----.--------- -- -- <br /> Water Supply: Public System and name------- ---- ------- -------------- ­------- - -------------------­ ­----------- -------- ---------- ----------- ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt d 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size---------------------------- -------•---- -----------------Liquid Depth---..----...-.-----.- ----- <br /> Ca acit ) -3 c-a T e..Pj'e.. GHyTMaterial....G.p1Y-1-1------No. Compartments_-.... .......... <br /> Distance to nearest: Well................A.p___ ......Foundation-.�-O. Prop. Line.. ��.$- -...-----........ <br /> LEACHING LINE [ ] No. of Lines _._.. . _ 1------------Length of each line--.....q _----.- ---Total Length �---------- -- - ----- <br /> D' Bax_ ___ . ..Type Filter Material.. de_�_-_Depth Filter Material...- o.i--- --------- ------------------- <br /> - <br /> - r <br /> Distance,to nearest.. Well---.-fb_p.�---.-----.Foundation------ - --- n <br /> ------ - --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 /> Septic Tank (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 / .6d '�` S��/ - --------------- -- - ---.....Owner <br /> BY------ --- . . .. <br /> Title ............ ------------------------------ ----- <br /> n own r) <br /> FOR DEPARTMENTIUSE ONLY <br /> APPLICATION ACCEPTED BY_. ..-------- -- ------- --- ------------- ------ - -----DATE <br /> DIVISION OF LAND NUMBER.....-..- .- - DATE --=--------------- - ----- - <br /> ADDITIONAL COMMENTS............................. -- --- - <br /> --------------------------- -------------------------------- .. .--- -----------------..........---. ...................... ------- --------- -- .. --... .- . -- . . <br /> ------------------------ ........................ .......----- ------------------------ <br /> ......... .... ...... ---- {'�� <br /> Final Inspection by:..... ....... .. --r ..--- -- ------.Date. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 2 677 REV. 7/76 3M <br />