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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------- ---------- <br /> (Complete in Triplicate) Permit <br /> --------------------------------------------------------- <br /> Date Issued_,7__f/9—_7 ` <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 19 <br /> Application is hereby made to the San Joaquin Local Health Distr'4ct 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/LOCATI N----2-��---g-l�----- _ z <br /> .. --CENSUS TRACT--------- -- . <br /> Owner's Name.,______ ff "ZNQ h <br /> 'Q'u -------------------------------------------- Pone--------------------- <br /> ------------------ <br /> Address <br /> ----- <br /> Address----- --- - ig 5 ''�� Cit Zip . y <br /> c � ----- ------ ---- --------- Y ------------------ <br /> Contractor's Na'me --•/ .Yo-_ 4icense # ZZ Phone-------------------- <br /> Installation-will serve: = Residence ❑ Apartment House,❑ Commercial ❑ Trailer Court ❑ <br /> :. _. Motel ❑ Other---- <br /> f -- - <br /> Number.of living units:................Ndmber of bedrooms-.-_..____".Garbo e Grinder...-.____._Lot Size___"_......__._...-....- __ "_--"- <br /> --- Priv <br /> Water Supply: Public System and name....... -___- ate ❑ <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 /> .� <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 TREAT&NENT <br /> [ ] SEPTIC TANK <br /> Size'--`-,;5-----=-------a----- ------------------------Liquid Depth - �------------- ---- - <br /> Y, <br /> - Capacity_ ,f'Type=Material------.6�_.-No. Compartments--------- 7----------- <br /> Foundation <br /> --- <br /> �...._,.,.,�.. �—�_.�._.._.�..�. - •,-"may.--:..� �-�-- <br /> Distance to nearest: Well------------- -�?----------.-- --Foundation---:- �C�.__.__---Prop. Line---- ----------_- <br /> --- <br /> . <br /> LEACHING LINE ( No. of Lines---------... . -.__ - Gp - <br /> ----_-..Length of each lina.._..�0l---------==----,Total Length._..__ . _- _ - <br /> _ -------- <br /> D' Box-.'-/....Type Filter Material _ ___________Depth Filter Material--------- f. .. .._____________------_--�-` . <br /> Distance to nearest: Well ------/ems_" ------Foundation....__.lQ.---_-------Property Line___aS__________________ <br /> SEEPAGE PIT f } Depth----------------Diameter--------------- ---Number--------------------------------- Rock Filled Yes ❑ No E] <br /> Water Table Depth-----------------=------------- ------ --- ---.Rock 'Size------------------------------------------------ � <br /> - <br /> Distance to nearest:Well------------------------------------- -----Foundation-------------------------.Prop. Line.-------------------------- k <br /> i <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----------------------------------------------------.Date-------------------------------------"-"----"-} <br /> Septic Tank (Specify Requirements)----- =--"-- ------------------ -------------------------------------------------------------- ---------------------------.----------------- <br /> ~ J <br /> Disposal Field(Specify Requirements):.... 71-OL19 �P �------------------------------------- <br /> -sce-2- . ' _- - ---------------------------------------------------------- <br /> -- <br /> --------------------------------------------------------° ; <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, 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 /> Signed------ - :. _ Owner <br /> --------------- <br /> - -- --- ------------ - - <br /> =-----=------------------ - <br /> By-- Title - <br /> ---------------------- <br /> '(If other than awner) <br /> I <br /> FOP,DEPARTMENT USE ONLY " <br /> APPLICATION ACCEPTED BY.---- - -- - ---------------------------------------DATE. f ------------------------- <br /> DIVISION OF LAND NUMBER------------------- - - DATE <br /> ---------------- <br /> ADDITIONALCOMMENTS ------------------ ----------------------------------- ------I--------------------------------- ------------------------ <br /> ------------------------------------------------------------------------------------------------ -----------------=---------------------------------------------- --- ---- ------------------------ <br /> ------=------------------------- ------ ------ ---- --------- ------------------------ - --- --------------- <br /> ✓ _ <br /> Final Inspection by:-"----. _ -Date-- _ <br /> EH l3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT y85 21577 REV, 7/76 3M <br />