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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> -- --------•-•---------- ------ --- ---------•------- 0 <br /> (Complete in Triplicate) �:f, 1 Permit No..7971 <br /> -----•-----------••------------- -- -- i-� 1� <br /> '-- ...... ... .... •-_•...._ This Permit Expires. 1- Date Issued.? <br /> 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 ADDRESSAC) ATION.. -- - - _ l5 � <br /> ........ ......... ...... -------------•- ......................CENSUS TRACT_ ----••. <br /> Owner's Name. �� �`y2 MA.-J <br /> -- . ... _ -- .. R C/pxZ <br /> - ...... .:........ :.... �--------.... - -......------- •----.......--�-- - ---------------Phone- �-'--`�-•---... - -•Address-. - .��........ �" (Ut <br /> q z .. ----- �-l(f�------ Zi S` GG <br /> -- ------ ----�----...City..--_._....�.___�--------------- --�-� p---------�------ --------.... <br /> Contractor's Name..__... !.le--- -------------- ----.----- .. . . ...._.License # CI r� Phone.. �. 3��'to/ <br /> ------ --- .. <br /> Installation will serve: Residence [' Apartment House ❑ Commercial ❑ Trailer Court ❑ '.. <br /> Motel ❑ Other--- ---------- -------- <br /> Number of living units:-..---- <br /> nits:.:..............Number of bedrooms_3____. .Garbage Grindar_.____...__Lot Size-------- __._ <br /> � � 3 <br /> Water Supply: Public System and name...... ..................... - -----��-.- ._ _._._..--___--Private <br /> ---------------- ............... . <br /> Character of soil to a depth of 3 feet: Sand E Silt❑ Clay ❑ � Peat ❑ Sandy Loam ❑-Clay Loom ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.. ..If yes, type---- <br /> ---------------------- <br /> (Plot <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 [ ] SEPTIC TANK [ ] Size ........ V.X _ ..k__S........ ............Liquid Depth.__4•/.l/ -r._.-------- <br /> �} <br /> Capacity. OwTYPe Pet►tsi ...Mat a1.-C v No. Compartments �1` <br /> Distance to nearest: Well-----------------`. - .� <br /> C16 .� .....Foundation--•--��f. .......... ..Prop. Line �.. ....... <br /> LEACHING LINE [ ) No. of Lines ...._-4- ------------ - L n'gth of each line---- .�---_-------_--.-- Total Length . :_ 1........_. ........ <br /> 'D' Box---I.i.....Type Filtef'.MateriaL._�.�!�.� _.Depth Filter Material-- -- 1- .��............................................... <br /> y '. r t i <br /> Distance to nearest: Well----- - .......Foundation------V------------------Property Line..-15--------.---.-------....._-- , <br /> E PIT [ ] Depth....:..... .....Diameter..__'-_------- --------Number---------------------- -._ - Rock Filled Yes ❑ No <br /> Water Table Depth---------------------------------------------------------Rock Size.---- "I. ... .....---....-------------- <br /> Distance to"nearest: Well--.-..-............................ --------Foundation------------ . .....Prop. Line..............-............. <br /> x1 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------- - - ---------Date----------_-- ------­..­ ------------ <br /> Septic Tank (Specify Requirements)----------- -- -- = <br /> Disposal Field (Specify Requirements)--------------------- ------------------ ------ <br /> ------•-----•----- - . •----- ....................... <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, aril Rules and 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 the work for which this permit is issued, 1 shall not employ any person in such manner as., <br /> to become subject to Workm4Compsafion laws of California." <br /> Signed._..... ---.-- Owner <br /> By..--------- �� --- ---- --------- . Title.----...------......------ --- ---..._. ......------------------...... <br /> (If otheranowner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY............. ............... DATE --------------- . ...7.��T-- ....... <br /> DIVISION OF LAND NUMBER.......... ...... . : DATE <br /> ----------------- ------- ----------------------------------------- <br /> ADDITIONAL COMMENTS....................... .. <br /> ------------------------------_. <br /> ..----- .. .............. <br /> ----------- <br /> ---- <br /> Final Inspection b ---------------...Date.-----...... -- - € <br /> eN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 f&5 21677 REV, 7176 3M <br />