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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------•-------------- ------------------ ------ <br /> (Complete in Triplicate) Permit No. ..-_' -- <br /> Date Issued-,3-A5_-.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 /> �.. ;�qfcry <br /> JOB ADDRESS/LOCATION...•--- .s _.Jl�---- /t_._..-- L.- -----•------------CENSUS Tji�ACT----- <br /> --------------------------- <br /> Owner's Name.... . ... ...- ................- -.Phone.P_5`34 ,77. - <br /> -------- - ---- ,... -------- <br /> -- ----------------._' ... <br /> Address.. Q...c� .�;1 !/. �-� ,!c.'ci City Zip .,__.. ... <br /> Contractor's Name._....... `f ' Q-� `T �' ---------------- ------ --------License #-. ._.. .....Phone...' . ' ._.. .. <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other............ . ... . ...... ---------- <br /> Number of living units:._--------Number of bedrooms_-. . Garbage Grinder------------Lot Size.-L.O. 'a -----.--. <br /> Water Supply: Public System and name-- ......................................... ...................----- -----------•----•--•------ ....................--------.Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay R' Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.. ... ....If yes, type-_-------------------- <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 /> e� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size - ------ -----------------------------------------------Liquid Depth....-----------------------p <br /> Capacity..--- -Type----------- <br /> Material--------------------------No. Compartments..................----------------� <br /> Distance to nearest: Well................................. .........Foundation---------- . ----_... . Prop. Line--.-------.--- ----------_ <br /> LEACHING LINE ( ] No. of Lines .................---------Length of each line --------------------_-------Total Length .. ..-----------------.--------------. <br /> 'D' Box- -- . - -Type Filter Material........ ..... .... Depth Filter Material................... .......-------------- ------------.--------- <br /> Distancee to nearest: Well---------------- - ------- Foundation-_.------------------ ......Property Line.......------- ----------.........-. <br /> SEEPAGE PIT { ] Depth-......... .....Diameter-------------.----- Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth------------------------------- - -----------------------Rock Size-- ........... .............. ------•----- <br /> Distance to nearest: Weil------------- ......__.... ............Foundation.......__-......... . -- Prop. Line---------------- <br /> (Prev, Sanitation Permit#----------------------------------- ---- ----------Date-------------.---..........----------------.-_j <br /> Septic Tank (Specify Requirements)----- . ..... --=----- ------- --------- <br /> Disposal Field (Specify Requir�efinents)_.............. <br /> -. {0.. ./YFQ.f.�J�'_ ..s. .. ''4 +4�,��y= <br /> .._..___•-_•--�._1_ ..5.. ..'. __�_£.... . .... .. ...... , .. ....................... <br /> ...._...-. •__ <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, I shall not employ any person in such manner as <br /> to become subjec to Workman s Compensation laws of California." <br /> Signed.--- . ------ ------- ........Owner <br /> BY ----------- --------- s°� ... .. ' -- - ---- -. Title. <br /> V. <br /> -------------- -- <br /> (if other than owner) <br /> FOR REPARTMENT USE ONLY p <br /> APPLICATION ACCEPTED BY-----1f1_101'1114.1t~' ._e_-1�o,_- .. .:8�----- ---- ------ --------------------- -DATE s�} .l-J-- --;/... --_--...__.. <br /> DIVISION OF LAND NUMBER.-------------- -- ........DATE............................... - - ..---- ..... <br /> ADDITIONAL COMMENTS. ........ ------ - ...... ------- .... ........ . <br /> ---------------------------- ------------------------ --- - .......... _ .....................­­.... ................. <br /> ---•--------------- ......... ----------- ...... .. ---... - -- ------- -----------------------.... -------- ----------------- <br /> -------------------------------------------- <br /> •------------------------------- ------------------------ ------------- - <br /> Final Inspection 6 <br /> Y:--- . -----... ---- - Date. =_. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fa lid» REV. 7/76 3M <br />