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r <br /> -y--,�-cflR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------- - ------------------------- (Complete in Triplicate) Permit No._�.7-.44e�F3 <br /> ------------------------------------------------- i <br /> Date Issued..- <br /> ---------------- This Permit Expires 1 Year From Date Issued i <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: i <br /> JOB ADDRESS/LOCATION --- ----- ~L p��- /f-� '-----�-� .-CENSUS TRACT-/------ -- -------------------- <br /> Owner's Name------- `-- ----- Phone----/--��-7_5r�� <br /> Address -------.----------------- ly�l._ ----------------------- -- -- --- ---- --------- -----------------City-- A a--D_ 1---------- ------ -------zip--------------- ------- <br /> Contracsor's`Narne__-y --- - /4U� -_le --- -w-----------------------I icense <br /> Installation 2will serve: Residence [V AApartment House.❑ Commercial ❑ Trailer Court ❑ I <br /> Motel ❑ Other--------------------------------------------- �- <br /> Number of living units----- ---------Number of bedroom st-- ___Garbage Grinder----------.-Lot Size---A;.i------ __---------.---.-___.--.___._ <br /> Water Supply: Public System and name--------------------------- l --------------------Private <br /> ------------------------------------------------------------------------------------- <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay Peat ❑ Sandy Loan ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.±:---------If yes, type- .---------3---.____-_____.- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ J SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth -------------------------- <br /> Capacity------------- <br /> .-.---- .-- <br /> Capacity------------- -------Type-------------------- Material:------------------- -----No. Compartments --------------------------------- <br /> Distance to nearest: Well-----------------------------------------__Foundation—-----------------------Prop. Line-----------.-------- =V� <br /> LEACHING LINE [ ] No. of Lines---------------------------- Length of each lin&-----------------------------Total Length-------- 0 <br /> 0 <br /> 'D' Box—---------Type Filter Material--------------------Depth Filter Material-------------------.-----------s-------------------------------. <br /> Distance to nearest: Well----------------------------Foundation-.----.---------- ------Property Line----------------------.---....____-.i <br /> SEEPAGE PIT [ j Depth----------------Diameter---------------------Number-------------------------------- Rock Filled Yes&E:] No ❑ <br /> Water Table Depth--- ----------- ----------------------------------------Rock Size-----------------------------------t------- <br /> Distance to nearest: Well-------------------------------------------Foundation ------------Prop. Line--------------------------- <br /> REPAIR/ADDITION.(Prev.-Sanitation Permit#-------------------- -7" ---- ----Date-. - __ --------------------- -]. , <br /> Septic TanV(Specify Requirements)----------I o'`-G --- --------------------------- ------------=- ----------------------------------------------------- - ----- <br /> G �� ------- - ` ------------ <br /> Disposal Field (Specify Requirements)----- _'_ _ ._ __ ____. __ _-;3I .- _7 � _____ __ <br /> 1 l -- .r-~ <br /> 4 .. _ _________ _______ ---l�-._._____.- -- <br /> ---------------------------------------------------------------- -- -----. — - . <br /> t 1Drayya.exi +ng and required addition;.on teverse side) <br /> I hereby certify that I have prepared this`dpplication and that the work will-be done in accordance with San Joaquin County <br /> Ordinances, State.ktyws'bnd Rules and Regulations ]of`the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the followirfg: ,I ' Yd <br /> 4 �r i'1. sR! <br /> "I certify that in the performanc`-e of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Wor marts Cainpensati" laws}-of California." <br /> Signed------ -- -- -- Owner <br /> ByY j ri. ------Title----------------------- --------------------------- --}------------ <br /> (If other than owner)' <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r L ------------- -------------------------- DATE. <br /> DIVISION OF LAND NUMBER... - ---._-.:"DATES: <br /> ADDITIQNALCOMMENTS----- - ----- ------ ---------- --------------------------- --------------------------------- ---------------------------- ---------- <br /> ----- --------------------------------- ---------- - --------- --- _ ------------------------ -------------------------------- . <br /> M ` --------------------------------- <br /> ------------- ------ ------------------------------------ ------------ ------^ ----------- . 4 . ---"......------------ - f` <br /> --------------------------------- - b f <br /> Final Inspection bY---- ------- �� Date ` <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r85 23677 REV, 7/76 3M <br />