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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------ --I------ -----­------------------ <br /> (Complete in Triplicate) Permit <br /> --------------------'-------------------------------- <br /> -.-I Date Issued..,--r,-W-79 <br /> ---------_----.------------- ------------------- __ This Permit Expires 1 Year From Date Issued <br /> v <br /> Application is hereby made to the San Joaquin Local Health District for a permitto construct and install the work herein described. <br /> This application is made in compliance with County Ord'lnance:No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA ION._-.-I./.. _._:_�-__ ...___..-.CENSUS TRACT <br /> li�.---'-- ------- - ---------- <br /> Owner's Name.-JW--- -- -- - ----------------Phone-----��-43�- <br /> ------ ------------------------------------ ---- <br /> Address 1�1 r -.-- -.-- r--- ------------------City 8�------------------------Zip-J,`5^. --- <br /> Contractor's Name__ G <br /> _ _ Bp ___________._License #_ ®S7 �____Phone.._ r�'���-3�-�3 <br /> � � __ <br /> Installation will serve: ,Residence [j —Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-------------- <br /> Number of living units:_,,,,�_.r----_-_Number of bedrooms---ZGarbage Grinder'------------ SizeraC_ ___'__ .------------------ ------ <br /> Water Supply: Public System and name----------------- -- -------- ----- -- ----- - -----:---------------------Private Q� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Pgat❑ Sandy Loam lay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material}_,_F,_._.._If yes, type ________________ <br /> {Plot plan, showing size of lot, location of system in relation to wells, bUldings, 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_-" .`_ J. <br /> ___ ------------------------------____------------Liquid Depth.- 4Q <br /> Capacity----------------- ---Type ----------------------Material--------------------------No. Compartments ---- ---------- <br /> Distance to nearest: Well--------- --------------Foundation __ Prop. Line.-----.-_---.--_.- <br /> LEACHING LINE [ ] No, of Lines--------------- of each line_---------------.------------Total Length-----__-----.------------------------ -- <br /> Type ----__Depth Filter Material__________---_-_ _ <br /> 'D' Box--:---------T a Filter Material-----------`- -------------------- ------------------ <br /> Distance <br /> ---- ------------Distance to nearest: Well-------------------------"_Foundation----------------------------.Property Line--------------------------------- i <br /> SEEPAGE PIT [ ] Depth---------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No❑f <br /> Wat.r[Table Depth .."kms <br /> Rock, --------------------------------------------- <br /> _ . , , <br /> Distance.to nearest: Well___ ____ --------r--- --------------------Foundation.-------------- ----------Prop. Line--------------------------- <br /> REPAIR/ADDITION.(Prev. Sanitation Permit# -------.___ -_A----------------------Date._-.._;.__-_--.---.-----..-_-_-----_--'--)' <br /> Septic Tank (SpeyRequir?,r s)__---r <br /> -- ----------r-- <br /> ---------------------�----"- r - __ <br /> __._ <br /> ---- -------- <br /> f r „Dispoal Field {Specify Requirem,efnts}._ __..__.. d1�---�- -- ----- -------- <br /> �----------- <br /> -Z�--�- ----------------- -- ----------------- -------- ------- ------ -------- <br /> -------------------I------ -------------- --------------- -if----------------- ---- <br /> (Draw existing and required addition on reverse'side) <br /> 1 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 shrill not employ any person in such manner as <br /> to become subject to Workm n Compensation laws of California." <br /> Signed------------ - ----------------- - --- ---------------------------------------------------Owner <br /> By- --------- �` - -- - -- ---------------------- -------------------------------Title---- O-,--------C;__Yet � <br /> Of other than owner) ' <br /> FCJR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- ------------------------------------------------------------------DATE--7 .2.l ----------------------- <br /> DIVISION <br /> ----------------- -DIVISION OF LAND NUMBER-------------------------- ----------------- ---- DATE.--------- <br /> ADDITIONALCOMMENTS------------------------------------------------ ------------------------------------------ -------------------------------- ---------- ---- ------------- --------.- <br /> -------------------------------------- --- ------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> --------------------------------------- <br /> Final Inspection by------ __._,__. - <br /> - - --- - -- --------------------------------------------------------------- ---------------------- - - ------ ------------ ---- <br /> - - -------------- <br /> - - ---------------------------------------- --- --------------------Date " Z" <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />