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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No....................... <br /> --------- --- -------------- ------------------------_ Date issued__.__ ._._..._._._ <br /> �/- 77 <br /> Y I` <br /> -_-_----- ....................................lff....__.._ This Permit Expires I 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 /> - _./ <br /> JOS ADDRESS/LOCA ION :.... --- ------- °..---------- CENSUS TRACT <br /> �� ---� �s 35r G� <br /> ,gyp � -._ �}. <br /> Owner's --------------- --------------= ----- Phone.__A <br /> Address 5_d�i'-- - ----------- -------.-----------;City---/ " � -------------------------Zip.-91-1.,P­--G----- <br /> i <br /> .. r .R � _Y f„. <br /> Contractor's Name_.. :- �(__-.-----:--- License #. Phone <br /> -----._-----= <br /> Installation,wiII serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------- = _ <br /> Number of living units:-- <br /> nits: ' Z_Number_of bedrooms-41� ' -_Garbage Grinder Lot Size - ------- <br /> Water Supply: Public System and name--------_ --- : _ . ---- -- ----- --- -_ -.--. _ -:. _. - ,; Private <br /> dp - <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ -Clay ❑ , Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan E] : Adobe] Fifl Material.. Yes.type-------------------------------- i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,.etc, must be placed on reverse side.) N <br /> NEW INSTALLATION: :(No.I�septic tank or seepage pit Oermitied if public sewer is available within 200 feet,) l <br /> PACKAGE TREATMENT [SEPTIC TANK - --- - -- <br /> [ ) [;) Size-----=_---------------- -' Liquid Depth- <br /> TYPe-------=-- --------...Material------------------------'--No. Compartments ---- --- --------- ---- f <br /> t bist5 nce-to nearest:..Well.,----------- ------------- <br /> Foundation _ Prop. Line - <br /> i <br /> LEACHING LINE.:, [ l . No. of Lines--------------- s.:..._ Length of each line-----------------------------=.Total Length---------------------------------------- <br /> Filter Sox_-:---------Type Filter Material ___Depth Filter Material ------------- <br /> � �,._ p .... ---------------�.. .. =------------Foundat!6n --------------------P'aperty Line----------- ------ -- <br /> h----------=----D.iameter- ,------------ <br /> Qist nce to nearest: We <br /> N'umber---------- ------'-------- Rock Filled Yes:[ No <br /> SEEPAGE PIT [-].�. :- De tl - - -. <br /> � . <br /> Water Table Depth. ------ - = Rock Size --------------- 5 <br /> f Distance,to nearest: Well- ------------------------------- __._-:Foundation.-:------.------_----._'...Prop. Line---------------- <br /> REPAIR/ADDITION (Prey. San6tion Permit#-----------------"----`-------------:----------------Date--::--,-----::-------------------°-----------_) <br /> Se tic Tank (Specify Requirements)- -c-1 - <br /> '(Specify Requirements)------> ` . L_ =/�' - --. --- -------1 -------------------------------------- --------- <br /> 'Disposal Field : <br /> I <br /> _______ ____________•_ <br /> ------------ _. _______ _-.__-___.--_ -_ ___ --__ _ __ ____ ----- <br /> i � (Draw existing and required addition on reverse side) <br /> I �by iertify that.l have prepared thisapplication-and that the work will be:�done in accordance with San Joaquin County' <br /> I Ordihances, State Lgws, and Rules and Regulations of:the_ San Joaquin Local'kealth district, Home owner or licensed agents <br /> sigiature.certifies the following: <br /> "I..certify that in the 06rformonce of'the work for which this permit is issued, I shall not employ any person in such manner as <br /> Ito become ubject fo" rk', 's Compensation laws, of. California.'" _... ._...�. <br /> Signed--- ------------- = Clvuner e <br /> - Y <br /> BY------- --- - `i - =-- -- - ----- --. ----Title-----�- ---------- --------------------------- <br /> I 1 ------ (if,oth�er-than-ownerl — -J <br /> FOR-DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY:Y' = -------------DATE --- � 7=-7�----- ----- <br /> DIVISION OF LAND NUMBER -=---------------DATE--------- - ;-.- ----------------------------- <br /> ADDITIONAL.-COMMENTS--- <br /> ---------------------------- <br /> ADDITIONAL..COMMENTS--- — - <br /> ------------ --------------- ------------'---------=---'----------------------------------' ------------------- <br /> ------------ ----------------- ------------- ------------------- <br /> ------------------------------------- -•--- - -------- - --------------------- ------------------ ----- <br /> Fina! Inspection by--- ------- - .f -� ----- -- - -- -- "-------=------------------=-------:Date____J.��_�. .. <br /> EH 13 24. SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV, 7/76 3M+ <br />