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x <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .7� �� ' <br /> (Complete in Triplicate) Permit No..... _____ __________ <br /> -------------------------------------------------------- <br /> Date Issued---- <br /> --------------------- ---------------- ----- - ------ - <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 ana`existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -oI .. ------------------ CENSUS.TRACT. <br /> f t �/Qr� <br /> Owner''s Name.. �'G�`Qr(, � �f�_ ,�. - e Phoney 1. 7 Z`� <br /> Address............... -----------------------------GZxCit: _.__0� --- --- --- Zi s ----------- <br /> Cont.ractor's Name— ____ .-___-_ ___ ._�; .- �_.__._!�L-icense #��_:�� �_�._Phone..�4 ___ _ _ _ _07___. <br /> � <br /> Installation will serve: ResidenceX Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> t ."� _ <br /> Number of livin units:__ t._..y.... ),. ._ ., Motel ❑- Other--"---( -'---=-----,------�,�`-¢-`-�-------------.= = ' � � <br /> g '__� ---_ -Number of bedrooms._�✓�_____Garbage G nder __.____Lot' Size_-._--_-._�z__ ". -_- <br /> { <br /> Water Supply: Publiti System and name--------------------------------------- -'-- -----'---------- ------------ --------=- _ ­______.1-- ------ ---------Private <br /> Character of soil to•a depth of 3 feet: ` Sand ❑ 'Siit�❑ "Clay[J ' "Pe at ❑- Sandy Loam ❑ -Clay Loam ❑ s <br /> - �.. Y - _ . .. ._. _ 4.. <br /> Hardpan 0 Adobe, Fill Material_'.= ""�:::If yes aype_._`_------- <br /> i L I <br /> (Piot plan, showing size of lot, location of system in relation to vvells,_buildings, etc.'must be placed on reverse side.) <br /> a i.. .. -i4 . U <br /> PACKAGE TREATMENT [ ] SEPTIC TANK - ''S el--,---� ' --' �. ; w iq feet,) <br /> NEW INSTALLATION: (No-septic tank -or seepage pit permitted if public sewer is available within 200 <br /> % <br /> ►CTS. /r° �"Tif1'�_No,iCom artme I ,r --------- <br /> Cap <br /> e � i <br /> r <br />• -------- ---� � Li uid Depth.+ <br /> Capacity:l ==TYPe . . . . Material P nts � <br /> i <br /> Distance to nearest: Well.'.----- d-f7!7--_ --------Foundbtion._._,_�_49.....:: .... ..Prop. Line..--Jl-�----�:--.- <br /> LINE [ Na. of Lines_-----_.- -------.---,--- Length of--each_Iine._.____ . __rte_ _ Total Len`gth.......f Z-------------------------- <br /> LEACHING 1 <br /> f _ . F - •, -� � 'fit ..... <br /> D' Box__.'�,._tType Filter Material__1_ Depth Filter Material...'_.._, ___.__ <br /> € Distance to earest: Well-:_3 �_ _- Foundati n-.. /D---y`-_Fj"'Property Line_ __- <br /> f <br /> SEEPAGE PIT a,. water �ble Depthmeter--.--�-__..---'__-Numbe ��Rock--------- ' Rock Filled Yes � No ❑ <br /> 17Y P <br /> s P - - ' $ize- �11 �1_L ------ <br /> ' Distance,to nearest: Well_.. --------- _Foundation__. _W�DProp. Line-�.r.-71-_____._.___..�t <br /> REPAIR/ADDITION (Prev. Sanitation,Permit'#__ -------_------------------------------_---------Date--._:----.__--.z:_--_-_ -_'--_�_- =- _.) <br /> f <br /> Septic Tank (Specify Requirements)--- t------=------ - - m­- ------------------= === == ----.---= --- :----_---------------------------------- <br /> ----------------------- -- ---- - <br /> Disposal Field (Specify Requirements) - ---- ---------- ----------------- ------- ---- -------------- --- - ---.--- <br /> i <br /> -----'--------------------------- -------------------------- ,_----------------- -------------------------- - . .- - ., . . ----------------- ---- <br /> �,,t - <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 16ccordance with San Joaquin County <br /> Ordinances,: State Laws, and Rules 1'and Regulations of- the San Joaquin Local Health District• Home owner or licensed agents <br /> signature certifies the following: ? i <br /> ..I certify that in the perforrn6iite'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.y' . <br /> Signed---------------------- ----------- =------ -- - -- -- -------Owner y <br /> B ------ `.----i/-.--- . ---r-.._ _� - - ---- Title �►�il -- <br /> ----- ---- - <br /> Y <br /> f other thbin owner) <br /> ,....M .r.. .... t ,. -FOR-DEPARTMENT <br /> USE ONLY. , <br /> i <br /> APPLICATION ACCEPTED. BY----- - • --------------------------------- '--'---}-.=DATE Y -� = <br /> DIVISION OF LAND NUMBER--------- -•- -- -=------- ------- --- ------------ ------------------------------------------------------DATE.` : ,. ` <br /> �. w <br /> ADDITIONAL COMMENTS------------------ ------------:------' ------------- ----------------- <br /> - ------------- <br /> - --------------------------- --------------- -------------------------- ----- --- ---------- <br /> - - - <br /> -- ------------ -- -- ---_..� ------- --- -- ------ -------------------- - ---------------------------- <br /> --------------- -----= ------------- <br /> Final Inspection-by., `-;Date-'-- <br /> EH 13 24 SAN JOAQUIN OCAL HEALTH DISTRICT F8S 21677 REV. 7/76 3M <br />