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F.OR OFFICE USE; FOR OFFICE USE: <br /> i I ��+ APPLICATION FOR SANITATION PERMIT <br /> ----------------------- 30--- <br /> (Complete in Triplicate) <br /> '' " Permit No.7 - .-- <br /> ------------------------------ --------- <br /> ----- This Permit Expires l Year From Date Issued Date Issued�d <br /> t <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. 5499a xisting Rules and Regulations: <br /> JOB ADDRESS/LOCATION <br /> _----------`-----�_�--.-�---. �y, -.CENSUS TRACT------------------ <br /> ------ -- -... <br /> Owner's Name--- - .Vn-0.,y-&..-..----GLV19P-- ------------- - ------------ Phone-----9�, ."" <br /> ----------- -- - - <br /> - -- e------ �.._.. --------------- - -- -------------City .ft)a l7-wC�----------- <br /> Contractor' - -.s Name_ �1 ---._License #-34cwq '9.,__--Phon <br /> Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Qtber---------------------------- ---------------- <br /> Number of living units:------1-.------Number of bedrooms__ ----Garbage Grinder__----------Lot Size_____________ --------- <br /> Water <br /> ______-Water Supply: Public System and name___________________________ -- -_.--_Private <br /> ---------------------------------------------- <br /> ----------------------------------------------- <br /> Character of soil to a depth of 3 feet. Sand , Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material-------------If yes, type---------------_--_----_-_ <br /> fPiot 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 [.I Size----------- --- <br /> _________________Liquid Depth--------------------- <br /> Com artments___--- .r <br /> P <br /> ------------------------ <br /> Distance to nearest, WIplf ------------ - - -----___ Foundation__1Q--___---.-- Prop. Line_+ <br /> LEACHING LINE [ ] No. of Lines.---3---5'"`Y-_ <br /> Length of each line. F Total Length. .__. ------------ <br /> `D' Box_-�Z__-_Type Filter Material__/22-----------Depth Filter Material­-_A?�_ � <br /> Distance to nearest: ..____---.__Foundation_ ©-.---_------___--Property Line---�?� ------------------------ <br /> i <br /> SEEPAGE PIT [ ] Depth -_._Diameter.._____..-----_____Number_______________________________ Rock Filled Yes ❑ No <br /> Water Treble Depth-------------- DE <br /> --------------- ---------------------------Rock Size----------- a - 0 i <br /> Distance to nearest: Well-------- -- Foundation------.--_.__--.- --.Prop, Line.--________----._ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----------------------------------'---------------Date---------------------__-- <br /> - ) <br /> Septic Tank (Specify Requirements)--------------•__--_-..____.-- <br /> Disposal Field (Specify Requirements)--------------- - k <br /> -------------------------- ------------------------•------------------------------------------------------ -- --------------------- ------------------ <br /> ---------------------- -------------------------------------------------------- ----- <br /> (Draw existing and required addition on reverse side) <br /> I 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, 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, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> r <br /> t <br /> Signe --------------- <br /> - Owner �- <br /> By @ �--rd <br /> - - - ------ ------------- ------------ Title---* <br /> itle -- --- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- -- - ------- - -- - - - --------- 7DATE <br /> ATE.__- c ___7- -- <br /> DIVISION OF LAND � - <br /> _.___.__ _______ - _._ <br /> ----------------- <br /> ADDITIONAL COMMENTS---------------------------------------- --- - <br /> ------------------------------------------------------------------------I------------------------------------------------------------------------ -------------- <br /> ----------------------------------- --- -------------- ---- ---- --------------------------------------------------------------I------------------------------ --- --------- <br /> ---------------------------------- -- -------- <br /> -- - - ------ -- ----------- ------------------ ---------------------- <br /> ---------------------- <br /> ina Inspection by: Dnte <br /> ert 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />