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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No----- <br /> __.__:_______� <br /> Date Issued =�-l.?-77 <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 /> JOB ADDRESS/LOCATION.. �� 'J>r -, A�-- F' CENSUS TRACT.----------- <br /> Owner's Name{: / - ------- ----- - ---- ---------- --------------Phone-------- ---- ----------------------- <br /> Address------ ..C�_.f - Cit Zi <br /> --------------------- Y - -- ---------------------- P--- - ------------------------ <br /> Contractor's Name - --- ---- ----------- .. -.--- - --- -------License #. •� _���Phone-------------- -- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] <br /> Motel ❑ Other----`---------------= r . <br /> Number of living units:-----/..:--' _Number of.bedrooms___7�Garbage Grinder------------Lot Size--------- --- ---------- <br /> ---- _ __________..____._._._.,.. <br /> Water Supply: Public System and name;. , --- ---------------------------------------- ----------------------Private <br /> Character of soil to a depth of 3 feet: Sand Elilt El Clay E] Peat ❑ Sandy Loam E] Clay Loam E_Hardpan E] Adobe Fill Material-. ----------If yes, type--------------------------------- <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 se age pit permitted,if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT K �\�X l-- --------------- <br /> PACKAGE iF <br /> [ ] SEPTIC TANK [ ] Size_.:_ _. Liquid Depth__.____;_ <br /> ------------- <br /> �.Matsrial . No. Compartments ?� <br /> • � CapacitY---��-.----�------TYPe-=-- -- � �� - P ------------------------- <br /> D <br /> ----------- <br /> i Distance to nearest: We1L...........N_Q_ -. ___.._____._Foundatian.____I_G_4..;?----------Prop. Line._4v3____r-- ._ <br /> LEACHING LINE [ 1 No, of Lines----------y---------- Length of each line,.______-�T_U_ _._-.Total Length.____-_lC _____._-.I <br /> f pp < < <br /> D' Box-_-- ___-'--TYPe Filter Material-----------1�_____Qepth Filter Material--------�-�----------------------------------------------�a Distance.to nearest: Well--.-- t<_Q�_.. .___Foundation-.--_.-1.Q_. ``_-Property Line_.____s _ <br /> rt <br /> SEEPAGE PIT—[,] Depth._._°__.____--._Diameter----------------_____Number---_-------------. -_- Rock Filled Yes ❑ No <br /> i � ------------------ ----Rock Size <br /> .. \ Distanee.to Depth.-------- - - - -= ---- -------------------- -- <br /> Water Table <br /> Inearest: Well--------------------------------------- ---Foundation--- -----=------=--------.Prop. Line ------ ---= F <br /> :� -------Date------.--------------" ----1 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#'_________________--------------------------- -----___--__-______- <br /> Septic Tank (Specify Requirements) • =----------------------------------------= Y--- ---------------------- <br /> DisposalField {Specify Requirements)----------- ------ ------- -----------.------------------------- -------- ------------------=----------------------------� ;--- -- <br /> J; <br /> --------------------------------------- L. <br /> } - _(.Draw.existing and required addition on reverse side) <br /> I hereby certify that I have prepared this applicdtion 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 C ensation laws_of California." <br /> Signed --- -- 1(,y -- - Owner <br /> r <br /> #------ --- --------------- --- - ----BY <br /> eca-C•n-- <br /> + '(If other than"owner`)' 1 ' t <br /> /71 R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- <br /> - -- - 1 DATE. f <br /> -------------------.----- - --------- <br /> DIVISION OF LAND NUMBER.----- . ------------------------ ------------------------------------------------ --- DATE- -­--------- = ------- <br /> rr ADDITIONAL COMMENTS.------ -- -----,--- --- ---------------------------------- <br /> ---------------------------------------------------------------------------------- <br /> _________________________________________________ ------------------------________.---------.------------------.._. ------------------------------------------- <br /> ____________________________________ _ <br /> Final�lns ection b -- -- - ----Date--- --------------------L---------------------- <br /> EH <br /> --------- -- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />