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FOR OFFICE USE: ✓ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No2g-=4. <br /> -------------- <br /> --------------------------------- - ... <br /> (Complete in Triplicate) <br /> -----•-•---- -- <br /> Dote Issued--P/.'f 2 ---- <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 and existing Rules and Regulations: <br /> JOB ADDRESS/ . . - . .........� ----- -- ------ ------------ --- <br /> .CENSUS TRACT-Z�............................ <br /> �^ . . ....Phone20VIA94 <br /> Owner's Name..... /K.Q��!4?..TTJ�R�.. .. .LD�.... -R�•.�'--- : -- <br /> ' f. .. city <br /> f Zip <br /> F <br /> - S - ....... . .-,..Phone. <br /> ---------- ------------------- <br /> Contractor's <br /> ------------ --...Contractor's Name-------/��' ............. ..• - -........ ---._. .... License #------ --------- <br /> --- <br /> Installation will 'serve: Residence ❑ Apartment House ❑ Commercial E] Trailer Court El <br /> Motel ❑ Other--.--. <br /> Number of living units:..`.0-_...Number of bedrooms--_0_`.Garbage Grinder.-P" -Lot Size--------- ----- - <br /> Water Supply: Public System and name .... ..... Private ❑ <br /> Character of soil to a depth of 3 feet: Sand E] Silt El Clay El Peat ❑ Sandy loam, Clay Loam El <br /> . tee <br /> Hardpan ❑ . Adobe ❑ Fill Material . .._ ..If yes, type................fv4 <br /> (Plot plan, showing size of lot, locatiori 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 SEPTIC TANK [ ] Size....... � oQ,� -----Liquid Depth.' <br /> Capacity Type _.....Material - -------•--------No. Compartments. .---..�-......---.. <br /> d_� . Pro Line... - -.... <br /> Distance to nearest: Well.............��-.= . .- � ---------Foundation...._. ../ <br /> p <br /> ----.. Ft <br /> LEACHiNG LINE [ j No. of Lines ........ a -�P- <br /> 'D' Bax��..._ TYpa Filter Material. _m2.`. k'Depth Filter Material._ ......_.- <br /> r/# e-J <br /> Di stance,to nearest: Well__4'� J <br /> Foundation------ .a.-F-P------Property Line.......5 .Ft._...--... <br /> Diameter....- ----.- Ed Rock Filled Yes No <br /> SEEPAGE PIT [ ) Depth.. ..� .r Number_.: <br /> Water Table Depth-=--- `.r .- .. Rock Size.- -- .... 2-.... ------.•-------. <br /> i -----Foundation__.... 7f'- Prop. Line.._.v ... F ------ <br /> Distance to nearest: Well_-...�. <br /> REPAIR/ADDITION (P rev-,Sanitation Permit#-----------•-•- --------- ------- Date <br /> Septic Tank (Specify Requirements)---- --------- ----- - ....................................------ . . - <br /> Disposal Field (Specify Requirements)--.;-------- ----- --- --- •. .... --- --------•- ........_.------ ..... . <br /> -------------------- .....--------------------- ------------------=------- - ---------- ................................................. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to beNomubi,eco Yfl/orkman's Compensation laws of California." <br /> SigneJN. oh. <br /> Title.. ..... t <br /> (If other than owner) <br /> O DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------- - ------- /Y�° ........ .. <br /> -- ----------- -------- --......DATE ......._ .-L7..�-- ... -------- <br /> APPLICATION <br /> - -� �- ---.. <br /> DIVISION OF LAND NUMBER.. ... ..... ................ .------------------- ..... <br /> DATE........ .... .. ..... <br /> -------------- ------ <br /> rr -- -------------------- <br /> ADDITIONAL COMMENTS........GLi. ....... ...... ..�- ----- -�----�- <br /> r - - <br /> -------------------------------- --------------- ..........---------------------- . ---- <br /> -- ...- .. <br /> I 9!4 --------------- ----------------- <br /> Final lnspect�an b ,-....-. . Date. <br /> Y.-.--.. . --------------------•----...- <br /> �. FSS 2167? REV. 7/76 3M <br /> � EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT t� <br />