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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT � �9 <br /> ---------------- ------------- ." -' <br /> """ -- ----- (Complete in Triplicate) Permit No.--- -- -- <br /> ---------------------ADate issued-----'----'- <br /> ---'---' <br /> .1--------------- -----TV --- ----------------- -- 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.. ----------------- -------------- CENSUS TRACT------- -- ---- <br /> ----' - 4�,,'�---- ✓J .:_t Phone". _ t <br /> ,/ f <br /> Owner's Name_..F� - -��f ✓L.Z� :.:. ; <br /> Address <br /> �-7 _-, Zip' <br /> a � ,. •, � -_ ---- --- - Ute.+•.. 1 <br /> Contractor's Name._/7' -- ___:-✓il. �-17'z7.P�.--''---•7� �'� ' License #_ P -�---Phone,. j -- <br /> Install <br /> at1on'will serve: Residence ❑ Apartment House.❑ Commercial [j�!Trailer Court E] <br /> s Motel ❑ Other------------------------------------ .: <br /> I <br /> ` g Grinder-._ Lot Size --------- <br /> Number of living units:,____---_ <br /> l -� ,n Number.of bedrooms_".____---_.Garbage Grin s , <br /> Water Supply: Public System and name- ------- ----------=---=-----------------=---- ----- '`----- ----.�_�--------------- --------------------------Preva <br /> te� <br /> ClSdracter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam,] Clay Loam ❑ <br /> iHardpan ❑ Adobe ❑ , Fill Material-_----------If yes, type--______{✓v i___". _ .: -� <br /> e-T <br /> f (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> i <br /> " .-A. <br /> {No;septic tank;or seepage pit permitted if public sewer is available within 2d0 feet,) <br /> } /PACKAGE SZ <br /> NEW INSTALLATION: <br /> TREATM NT J ] SEPTIC TANK [ ] Size-- -- --------------------- �--'-� --- -------Liquid Depth------------- ----- ---- <br /> t tCapacity�" _C3 :_._Type/��c �f -MaterialC�car•�c."`/--'--Na. Compartments --___ <br /> !Distance to nearest:Well._ C�QC7 ----Foundation Prop Line_fQQ ._._ <br /> j� <br /> F <br /> LEACHING-LINE [ ] No. of Lines :� .--___ Length_of-each-line�� ",�� '------:Total length -_ ��-� --' <br /> t ; IEACHi r I t <br /> G f D' Box.... ."_.Type Filter lNaterial--__A u___ Depth Filter Material--. :----- ". ------- --'-F.__---- ,---' <br /> 1 f'Y Distance to nearest:Wei --- .?." ------Foundation _ri;C< z> 1t----------gProper.ty Line_.��j_C�_r- r------------ <br /> Rock N <br /> ------;-----'---------- Fill r Yes ❑ o❑ <br /> SEEPAGE PIT [ ] Depth____ - Diameter_________________" "Number__' <br /> Water Table Depth1------ -- -- - 4]------ .Rock Si e-------`-------=--------------------------------- <br /> I <br /> -----=------ ---- ------=----- � <br /> 'k I k ( t <br /> L - --------- <br /> ;� Distance to nearest: Wel[--'----- -------------"_"--- ------------ <br /> ------------------ <br /> bate <br /> - "��Foundation.��.�- -- -------"_--�-.Prop. Line-_--------- _-"-- <br /> ns u I f I - _ <br /> .REPAIR/ADDITION (Prev.,Sanitation Permit#------------- -` ----------- ------------ <br /> ------ <br /> ----`--.:D�aj e =11 f -: � ) <br /> ' ,_ I t - ' <br /> Tank (Specify Requirements)--------- ---------------------- - - ---- - ---=--- ------------------------ <br /> Septic ; <br /> 1 Y <br /> Mfr- � <br /> ' <br /> [ i t a <br /> -- ;-Disposal'Field (Specify Requirements):_-------_______----- - ----------- ---- --' ---- -------------------- -- ----- ---------- ---' ` <br /> ----- <br /> - --- ------------- <br /> ` <br /> t - <br /> - ------------- --- ----- ----- ----------------- ---------- ----------- - _ --- --- <br /> =------------ L------------=---- <br /> ss-------------------------------------- ----------------------------------------- <br /> (Draw existing and required addition on reverse side) = j <br /> I heroby certify that I,have prepared,this application and thatjhe :work-will be done in accordance with San Joaquin'County <br /> Ordinances, State Laws,"and-Rdles 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 pe+#ormance of the work for which this permit is issued,'I shall not employ any person in such manfrertias <br /> to become .subject to Wor an's Compensation laws;of, California."J.i <br /> Signed <br /> ¢ '---- ..... Owner <br /> > .-- -- . . _ -- ------- LSC .. . . <br /> - <br /> By --'=-- :--------- ---------------- ---'"----- ----- -----:------- . <br /> Title-------------------------------------- -------- ----- ------------ <br /> - a <br /> t F"""(If'other than'.owner♦ <br /> FOR DEPARTMENT USE ONLY <br /> I APPLICATION ACCEPTED BY'------ -- --- -- -- <br /> _DATE ___.45Z---------{----- <br /> -_ --'------._". <br /> DATE <br /> DIVISION OF LAND NUMBER._ ---------- ---- ------"------------ :: ' : ' <br /> ADDITIONALCOMMENTS-- ----------------------------=-------------------,-------------=----------- ----- -= <br /> ----------------------- ----------- <br /> ------;------- , <br /> --- ------------------- -------------_------- --- <br /> rf .�- ' ------- ------- ------ --- - - --- ----- -- <br /> ------ --_--- = = =- ----------------- <br /> !� . <br /> Is%i' '"' -------------'---- ----------------' - <br /> -----------------�--------------------- T <br /> �- .� _. . Date - - ?rZ_- 7 _ -------------- <br /> Final=Ins coon b - �_ <br /> FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />