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FOR OFFICE USE: <br /> 1. FOR OFFICE USE: a <br /> - pp ., . APPLICATION FOR SANITATION PERMIT <br /> Ic ------------------------------ f (Complete in Triplicate) Permit No.....7�.�(� <br /> ..................... ---------------------- <br /> Date Issued.../`-,�-(;.-n7. <br /> .............................._:............------------- This Permit ;Expires 1 Year From Date Issued <br /> � a <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: K <br /> JOB ADDRESS/LOCATION., ........ ---------- ...... ------.CENSUS TRACT.. •--•----- ....... <br /> Owner's Name3{. Phone._ a . <br /> } ,gyp � � f/ J <br /> Address . - .. ... , s, �, .......4i.OIC---- . . -- City 16,1 )'SAX.----.. . ...Zip i sa�-C1 - ----. <br /> Contractor's Name.�yk�& .+ A . �1fif��,,�i�l�.t"�1G?.C�.---.License #N_?_S Off _P� ��..--- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Courts <br /> Motel ❑"u„Other`....... ....................... <br /> Number of living units:.. .._.Num}�er-of bedroorris_........ Garbage Grinder--- --------Lot Size 10.-y-ovo------------- <br /> Water Supply: Public System and name- -. -------- ;r :.... _._ i -..Private ❑ <br /> - <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loom ❑ y Loam ❑ <br /> Cla L t <br /> Hardpan ❑ Adobe❑ Fill Material._ ........ If yes, type-_----------------------------- <br /> (Plot <br /> - - ----- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) . C YI <br /> NEW INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) N <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-------- -------------------------------- - Liquid Depth.--: <br /> Capacity ` Type................ . ...Material,-------------- ----- ---.No. Compartments------ •----- <br /> Distance to nearest: Well--------------------- ----------- - Foundation--.--- .....'.... . ..Prop. Line.... <br /> LEACHING LINE ( ] No. of Lines .. .........................Length of each line ------------_--- ---------Total Length <br /> 'D' Box-- -....Type Filter Material.._.. --.Depth Filter Material:--. ........................ .-------C <br /> Distance to nearest: Well-------------------------------Foundation-----------`---=---=----...Property Line-.--.-.---------------- ..... <br /> t- Depth--.---.. Ro <br /> .._..._Diameter------------------- Number.---------------------------Y-- ck Filled Yes ❑" No <br /> GE PIT Water Table Depth.--------------- -- ............ :------------_--.Rock Size--- ...... <br /> r Distance to nearest: Well_- ------_Foundation--- ----- ..............Prop. <br /> ! � _ <br /> )L <br /> ine. --------- <br /> REPAIR/ADDITION <br /> -----... <br /> PARTADDITION { vsSanitation --.... -- ,.-.Date--..---.I.............. --- <br /> SePCISP Y Requirements) ---------- -- s V <br /> -...'r` <br /> Disposal Field (Specify Requirements) ..XAe1PTfr......._ ...............-----•-•----. .............. --...---- ........I--- ---------• :.... ---- ----- <br /> --------------------------------------------------------------I-------------------•---- •- -------- <br /> ------ ----------` ------ ..--•-.-•--- <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, Hoene owner or, licensed agents <br /> signature certifies the following: w _ w <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 Owner <br /> By- <br /> Title... <br /> . --- . ---. -, <br /> (If of -t an ow r) <br /> r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � ----- -- --------DATE.--- - _...J�................ ..... <br /> DIVISION OF LAND NUMBER.--.............. ------------DATE...... ----_------- ----- -- -- ........ <br /> ADDITIONAL COMMENTS......0A— �.�rt <r v't + J K�- --------- ---------------- <br /> --------------------------------------- <br /> ..------------------ --------------- -- ------. ---- ..............­--------------------------------------------- <br /> ---�---`------ <br /> Final Inspection 6 ......Date. V .�. �.g <br /> eH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Ess 21677 g v 7176 3M <br />