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FOIL OFFICE USE: FOR OFFICE U5t: <br /> j��/ APPLICATION FOR SANITATION PERMIT <br /> ----------------- ----•- /... Permit No..2.8*-r&OZ <br /> _ (Complete in Triplicate) <br /> ----------- •-- ----- -------- <br /> ,- --•-•.,- •---� Date Issued.??.:.IPa--2 <br /> ......,5.. ----------------------- ------- 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/LOCATION....... S5 ---- -------- ---------------- ---------- <br /> CENSUS TRACT.. <br /> Owner's Name.... .[ ---------.Phone.--.���.� �4-0.-...- <br /> a. -. <br /> ZG. .SS ..._.- .. :. -'r-O'rz-cl , .. Ciry sGc �q "'-•---------------- Zip--- C5 `6 -- ----- <br /> Address.............. <br /> Contractor's Name...... ---- ---.✓'�--.- .. . --- License #. •-----. .Phone_.....-:. r.... <br /> Installation will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ f <br /> ti Motel F-1 Other......­­------- -- A <br /> •-------- <br /> Number of living units:----...1-------Number of be&ooms__Z_....Garbage Grinder--.A/o--.Lot Size..... ...... <br /> +rte.,-- -,s ' ; _... . -----1 <br /> Water Supply: Public System and name-..`..� .. ............ .,.........Private <br /> Character of soil to a depth of 3 feet: Sand [DSilt E] Clay ❑. Peat El ' Sandy Loam Clay Loam E] i <br /> Hardpan-Fl- -Adobe ❑ "Fill Material ..If yes, type............................ <br /> E <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc mu`st-be placed on reverse side.) <br /> NEW INSTALLATION: (No 'septiL tank or see age pit permitted if public sewer is available within 200 feet,) fi 'j <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size......_-----IV ---`---k.9-------------- --•---------------Liquid Depth._. ..G..----......� <br /> �rC1' i] , I"C'Co5 f Matarial_..0 ?�/C".. :No. Compartments..-•-- •-------- 4 <br /> Capacity .1 ,<�_.... ]IType <br /> Distance to nearest: Well--1---------�0 -- - . . .....Foundation-------.--� d--........Prop. Line-__27 .....x...... <br /> -, <br /> t� l i <br /> LINE [rNo, of Liries____......��-.-... -....Length of each lino------.. d----------- --Total Length .....--i -.... �?'............h <br /> LEACHING D' Box.... .Type-Filter MaterialSr_�rrDepth Filter Material-------------_.------------.--- ..----------- ........... <br /> Distance to nearest: Well__.. �d----..---...Foundation----- `v-------------Property Line...-•- - --/-------....... <br /> i - Rock Filled Yes No <br /> SEEPAGE PIT [ ] Depth---------- --- Diameter..------:-----'..-.Number---.------••------------------- ❑ <br /> Water Table Depth------------------ --- Rock Size <br /> ...- <br /> Distance to nearest: Well.....--.'-----!--. -------------•-Foundation-,----------... ---......Prop. Line.----------------------- <br /> - <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_---.-•-------'- ...--.......-...............Date-----------------....-.........-......- i <br /> Septic Tank (Specify Requirements)--------- ----------- ---------- ------- <br /> Disposal <br /> -----Disposal Field (Specify Requirements)...................... -•........--- ------------------------ - ----------••------•-•------ - <br /> ------------------------ <br /> •--•--•---------------- ------------------ .......... .---- - ---­--------­-- . ----------------•--------- ----- ............ . .... ------............ ............ <br /> - -------- ---------------------- <br /> (Draw existing and required addition on reverse side)" t ' <br /> I hereby certify that I have prepared this application and that the work will be dnne 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 sub' ct to W a 's Compensation laws_ of California." <br /> - k <br /> Signed. - ---------------Owner s <br /> ........:Title------ --- -------- -------- -------- <br /> (If other than owner) <br /> PCIA JDEPApftMENT UjEj9NLY <br /> APPLICATION ACCEPTED BY............. ------ -...-----DATE .........�--- ..2-� .. g <br /> DIVISION OF LAND NUMBER..-----_-------- - DATE <br /> ADDITIONAL-•COMMENTS.. — - ---_�.-:--- . — :- - .-_.:. . - <br />'€ <br /> ........... -- <br /> ----- --- - --------- ------- - .._. _... { ------ •----....-- --- --.....-_ <br /> - <br /> ------------------------------------- -- --- . - =_----------------- ..---------------- ------- <br /> Final Insgeaion by '----`i. --------- <br /> Date.... <br /> I� EN is 2a SAN JO QUIN LOCAL HEALTH DISTRICT C� Fas sia�r Rev. ��ia ann <br />