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L FUR OFFICE USE: ,° FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------ ----------------------------- <br /> (Czmplete in Triplicate) Permit No.- _a <br /> ?� <br /> Date Issued___ __-2-_� <br /> ------------------------------------------------------ -- This Pern it Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Ocal 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.--.--- - - ---0 2.C�CF�r C�--•-•--------------•---------------CENSUS'-TRACT.-}------ <br /> Q <br /> Owner's Name --------- ----�--- -- --'--- -- - C.1.CJ-!�:��--- -- -.,.,��r_M�. - - ------ ---- ----��-----Phane_../.:_��_----- <br /> Address --- -- .�. - ---- ---- .+ '. City zip <br /> --- /------ <br /> Contractor's Name------------------ ---------- --- - - ---- ---- -- --. :•:*.License #Z_y.'1!U------Phone-566(I/-,-_- F4�07_._. <br /> Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court ❑ <br /> Motel ❑ Other-------------------------- -----_----- <br /> Number of living units:_____ -------Number of bedrooms----_3----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 ❑ . j <br /> Hardpan ❑ Adobe Fill Material------------- yes, type------------------------- <br /> r <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 4� ' <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK ��} Size------- i - �� <br /> I l p �---�--�-- - s <br /> -------------Liquid Depth -�'----, -- ,_ <br /> Capacity-- -------1-----Type--- ---d-`--�+ ---------Materiaf__. c---- -No. Compartments-- � - <br /> i <br /> Distance to nearest: Well.-------./M------------------------FounclaTion------,lQ-------------Prop. Lir1e---2------------- ------ <br /> i t :y.: .. i f <br /> LEACHING LINE ( No. of Lines-------- ___.__.__.__.Length o ea Iina.------- _.;___.__.__.Total Length-_-lQ_ <br /> 'D' Box__-_Type Filter Mat ---- _.Depth Filter Material____---1.8-- ___..r.__''------------- <br /> ( N <br /> ' ----------Property Line__629-------------------------- <br /> Ia� `r Numbers + . <br /> Distance to nearest: Well___ __b---- ------------Foundation-_- - p <br /> SEEPAGE PIT � Depth.__ _--____Diameter._. ___ _.,. <br /> _ _ <br /> Rock Filled Yes No ❑ <br /> Size�.I <br /> Water Table Depth Rock Size_. ; ' <br /> �. s <br /> r ._ _. <br /> Distance to nearest: Well_.__-_/ _________________________Foundation.__rlO_ 'ir"�..__.Prop• Line_._ _-- -_ - <br /> REPAIR/ADDITION (Prev. Sanitation Permit#- -----.Date--: --------------------------------------1 <br /> Septic Tank (Specify Requirements) '- _-- =_ _ .... <br /> -- �- —� - <br /> t <br /> Disposal Field (Specify Requirements)---------------------------------------- �_------------------------------------------------------------------------ <br /> ,1 R � <br /> --------------- <br /> -------------------------------------- ----_------------------------------------ _ <br /> (Draw existing and required addition-on reverse side) fi <br /> I hereby certify that I have pre'pared.thls-application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State taws;.,ancl�Ruies and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the follow ng: <br /> "I certify that in the peirformance 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 /> I <br /> Signed--------- - ------ ---- - ---- �__ - Owner <br /> r <br /> BY-------- ------- - ---- ---- --- ------- <br /> other <br /> ---other than owner) <br /> ' r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-._ -----`---------------------------------------------------------- - DATE:-----'-= -"7-- -- -- ------- ------------ <br /> DIVISION OF LAND NUMBER.- •----_- ---_. - -----------------------------------DATE.------------- <br /> ADDITIONALCOMMENTS.--------- -- ---------------------------------------- ------------------ --- ------------------------------------ --- - -------- ---- ----- ------------------------- <br /> =-- ----- ----- --- - ---- - - _ <br /> 3 - -- - F -------- --- <br /> = -- ----------- ---- --------- <br /> Final Ins ection - " <br /> P Y�-- -� ----- -------------------------------- ----- - - -----------`-`---------- ----`---�-------------Date -�Q�--=� - -- ----------- --- --- --- <br /> EH 13 24F&5 21677 REV, 7/76 3M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />