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FOR OFFICE USE: . FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT V��Permit No <br /> . --"(Complete in Triplicate) p �f <br /> Date Issued.��,A -_; <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 /> JOS ADDRESS/LOCATION.. I-?EfYIPA(77 ------ -------5_TiE�i , CENSUS TRACT...---...-----------.-.. . -- <br /> Owner's Name.... Ltq_w . ��/7 3E1QXu%.............. .......... ... PhoneCy�� 73t-SSS< <br /> Address----- <br /> Contractor's Name.... - - . ..... .O <br /> cense .oone.- .� ............ <br /> Installation will serve: Residence ❑ Apartment House ❑ _Commercial M Trailer Court <br /> Motel El Other _ <br /> Number of living units: of bedrooms_...-. Garbage Grinder - ._... - Lot <br /> Size..............._..,. . ................................... <br /> Water Supply: Public System and name....... . ... ..f:�- . --- ---------------------Private <br /> �. --- - -.. ... <br /> Character of soil to a depth of 3 feet; Sand ❑.. Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ <br /> Hardpan p ❑ Adobe Fill Material._ .... ....If yes, type-------------------------....... <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 200rfeet,] <br /> PACKAGE TREATMENT ,�[� ] SEPTIC TANK j ] .F Size/---------------------------------------------------Liquid Depth_..."._._._..--------.-. <br /> Capacity............. -----T�pe---- Mate-vial--------------------------No. Compartments_.---------------- -------- W <br /> Distance to nearest. Well.---............ ...................... Foundation....-- - Prop. Line------..._.------.. .-...... <br /> LEACHING LINE [ ] No. of Lines .----"--------------------Length of each line............................-. Total Length --------------------------------------- O <br /> 'D' Box .. ...Type Filter Material." -...Depth Filter Material-- ------- --------------------------------- -- ----- ------� I <br /> Distance to nearest: Well........ ........ ... .....Foundation...---------.__.---..-------Property Line...------.-------------_ ....... <br /> SEEPAGE PIT [ ] Depth----- --- Diameter--------..............Number-_-..------------------------ Rock Filled Yes ❑ No <br /> WaterTable Depth.................................. ......... .............Rock .Size.-- ..---........... ............................ <br /> Distance to nearest: Well.......... ........ .............____Foundation- .--.-.. ... .....Prop. Line.---------.-------.-.----- <br /> . i <br /> REPAIR/ADDITION (Prev. Sanitation Permit ------ --- ....... ..............-Date-------------- --------------------_--------] <br /> SepticTank (Specify Requirements)--- - -------• ---------------------------- ---------------.................... --- .. ....... ----L............ ------- --...----. <br /> Disposal Field (Specify Requirements)... / ST!9.LG_.----�,y�.... �i. ----------------------------------------------- <br /> . <br /> - `,..._ . ------ .......................- -----------------•---------------------------- ---------­------- • ....... <br /> ............... ------------------ <br /> (Dr.ow existing and required addition on reverse side) <br /> I hereby certify that I have pr pared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, Stale Laws, and Rusle an`d Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "1 certify that in the;performance�of th`e work for which .this permit is issued, I shall not employ any person in such manner as <br /> to become subject to <br /> . .. . Workman's'.Compensation4aws of Califor <br /> nia." <br /> Signed--- ----- Own <br /> er <br /> By....... ------ ---- ---- <br /> .....---.--.... Title.----_...4� ...------------- -- <br /> (If other than owner) <br /> .4 . <br /> F R DEPAATMENT USE ONLY <br /> APPLICATION ACCEPTED BY..... .......DATE ........ 7.7 <br /> t <br /> DIVISION OF LAND NUMBER. ..... ------------- ---------- --DATE. <br /> ADDITIONAL COMMENTS... �.�... Q, ,\" Z-" .. �`�------ . ............ <br /> ............... . ------ --------------- ---------------- --.... ---- -- --------------- ...... <br /> ----------------------- <br /> -----------%----------- <br /> ---------------------------- ----------- - ......... - r.. .................................... --------... ---._... ... ..... -- <br /> Final lnspeci�an by:. ----Date. <br /> EH 13 24a SAN JOAQUIN LOCAL HEALTH DISTRICT Fd5 21677 REV.%/76 3M <br />