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fi <br /> �i FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ^� <br /> (Complete in Triplicate) <br /> Permit No..!_._7-_ __.�� <br /> --------- ------------------------------------------ --- <br /> II Date Issued_--a3'7 7 <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 /> tj <br /> JOB ADDRESS/LOCATION f , - <br /> R CENSUS TRACT-------------s� <br /> _ ------Phone-77` 67 <br /> Owner's Name _ ------------------------------ - <br /> -- - - --- -- -- <br /> -- <br /> Address..--, ----- 7�S City--c'40 o e iP._ <br /> Contractors Name------- -- ---�' ---------- ----License #_7� 3 ---Ph n Y -- 6a7 <br /> �- i <br /> Installation will serve: ResidenceApartment House E] Commercial Trailer Court' ❑ <br /> ';; % Motel ❑ Other------ -----------------------=----------- - <br /> '- <br /> `k <br /> Number of living units:------. --- _ Number of bedrooms---- Garbage Grinder----------{_Lot Size.-- <br /> -1 .. <br /> Water Supply: Public System and'name---------------- ------- ---- -,----- ---------.-- -_- T _: --------------------=---------------:-------------- = --Private ❑ <br /> h <br /> Character of soil to a depth of 3 feet: ❑ Peat❑ Sandy Loam:❑_._ Clay:Loam-❑ <br /> j Hardpan EJ Adobe Fi11'Material____ ----If yes,typ ------------c <br /> - `t <br /> (Plot plan, showing size of lot, location of sys}errliri.,r.e{ation to.wells, buildings, et.must be placed on'reverse side.] <br /> NEW JINSTALLATION: (No'septic tan'Vor seepage pit,pe'rmitted if'public'sewer is avdilcible within.200.feet;) r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size----------------_- -° _-___.----------------- _-Liquid Depth-:_ci-.-----:.--_.---._. <br /> N Com a�rtments�- r , <br /> .,� Capacity ----- --- ---------Type. -- Material -------- -- p <br /> [ Distance to nearest: Well.........----------------------------------Foun_dation--..----._-----Mui Prop. Line----------------------- <br /> LEACHING <br /> .----. --__----__LEACHING LINE [ ] No. of Lines- =----- -------------------.Length of eachaine--------------------- Total Length.--,----.----------- ----------------_m <br /> D' Box_-....------Type Filter Material---------------- Depth Filter Mate ria l_, ��- _----.-�.--- <br /> =----------- --------------------- <br /> Distance to nearest: Well------------------- Foundation-------------------- t RrdpeitLine------------------------------- <br /> �- <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number---------------------------- Rock Filled Yes ❑ No <br /> E;- <br /> ii _ . <br /> Distan ea of nearest: Weil '--•------------------------------------ ---:---Rock Size------------------------I------------------ -- �V <br /> p <br /> I ------ -------- -- - - ----i -- Foundation--'------- ---------------.Prop. Line------ ------- <br /> REPAIR/ADDITION (Prey. Sanitation Permit#-4s•_- -_---_ _ __------: Date--------------------______________.__-____----) <br /> Septic Tank (Specify Requirements)_ ----------r._ 4` --•' € -- ------------------------- <br /> Disposal Field (Specify Requirements)__..____. -------- -------------- -----i---. <br /> -r.�-_: <br /> E, , t # <br /> ---- ----------------------- =------ -- ------ -- ------ ------ <br /> _�__ � _: k ------------------ <br /> w' <br /> `• . <br /> !' (Dra "existing and required addition on reverse side)'--Q � <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 /> lr <br /> By-, itle <br /> Tr.-, - - <br /> - -- ----- <br /> - { other than owner) ALk <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED• BY-------I-r.. -- DATE----------------r_�„3---- <br /> ------- ---- <br /> DIVISIONOF LAND NUMBER---- -------------------------------------/------------------- ---DATE---------------:---- ----- <br /> ADDITIONAL COMMENTS--------------------- --------------------------------------------------------- <br /> ----- <br /> ---------------- -- ---------------- ---------- ---------------------I----------- <br /> - - <br /> �i - <br /> -----= - ------ ---------------------------- ----------- -- -------------------------------------------------------- ---------------------------------- ----- <br /> } <br /> --------------- ------- <br /> FinalInspection-b ------------------------------------- ---------------------------Date------- ------------------- <br /> EH 13'24 SANOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />