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FOR OFFICE USE: = -° <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE"USE: <br /> r <br /> ' p p <br /> (Complete in Triplicate) Per mit.:No.� :1U 7 . <br /> ............................. ...... <br /> This. Date.`Issued.� - $� <br /> Permit Expires 1 Year From Date Issued =...?� <br /> Application is hereby made to-the Son Joaquin Local Health District for a permit to.construc <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules a and. <br /> Regultations: work herein described. <br /> JOB ADDRESS/I LOCATION....:........ ....:�_- <br /> i' ' ... -- CENSUS TRACL <br /> I <br /> War's Name.... .-- -. . <br /> --- --------------....... ...... ------ ---- ---- _--•--.Phone...-.....-- <br /> Address.... �y7, R ...-._ <br /> .---- ------City----- -- ---------- -•-------- . <br /> Contractor's Name....- 0 �! l <br /> 4 <br /> _4_77 <br /> c License_# 'J7 Phone- <br /> - -- -�---- - -- _ <br /> Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Mofel ❑ Other-- ._... - <br /> Number of diving units;_.... <br /> ........ Numb I er of bedrooms._-.._.._. Garbage Grinder............Lot Size..-........-..... <br /> ..-- <br /> Water Supply: Public System and name:.._.... . <br /> AP Y y <br /> O <br /> i '----- <br /> --- ------------------ -----------...Private ❑ <br />' Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay1, t < <br /> ❑ ` Pear ❑ Sandy Loam E Clay Loam ❑ ^ . <br /> Hardpan ❑ }Adobe L] 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK <br /> f } Size - ----- ----------------------------- _..Liquid Depth . --------...-- . ......N <br /> Capacity Type.-: -- -----.Material--------------- ........-No. Compartments.-------------- •----- <br /> DisNnce to nearest: Well------------------------ <br /> ---- ==E.aundation._--- i-- .. <br /> LEACHING : Prop. Line.- <br /> LINE ) l No: of Lines ..-._. Y, i <br /> a <br /> Length of each line.-.---------- Total Length _.. ..- -----. -- i <br /> D' Box.... ......Type Filter Material----- - ----- -- Depth Filter Material......._--.-------,------------------•-------- ------- -- <br /> ..--.. -- . .. .... <br /> Distance,to nearest: Well-............ ............Foundation._......--......... . Property Line... . --------..... p <br /> SEEPAGE PIT [ 1 Depth ............. €Diameter---------------.---.Number------------------------------. Rock Filled. Yes ❑ No❑ fi <br /> Water Table Depth-------------------------- ------------- r <br /> Rock Size' - ------ <br /> Distance to nearest: Well-------------------------I .. .............Foundatian.f------- .-.._._ ...._-Prop• Line.....-....--...... <br /> .-..---.. <br /> PAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------.-... ... -- } <br /> ... ate.-..-----�..... ....... ....... <br /> Septic Tank (Specify Requirements).-_--- . ------------------------- <br /> Disposal <br /> ._------. . .Disposal Field (Specify Requirements)_...._ <br /> 3I..: -- --.- ------33- = <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 />"1 certify that in the performance of-the <br /> work for which this permit is issued, I shall not employan <br /> to become subject to Workman's Compensation laws of California." y person i n such manner as <br /> i <br /> Signed... Owner , <br /> By....... qcf_� - - ­......I', <br /> --------------- <br /> ...------ -.. Title.-- -- ----- <br /> {I other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-'----,.. .. .. _ . <br /> ------------ ------------I--------------------- ------ -DATE .....\Z._. .�.... . - <br /> -----.-- <br /> ISION OF LAND NUMBER. .. . ----------- -- ------ ------- ---------- ... ....DATE. ...----.... <br /> ADDITIONAL COMMENTS.... ...... <br /> ............ ..... . <br /> ........... . .. ........ ....1.­ �i <br /> ---- <br /> -- ---- ------ ------------ ------------------- ---------: ..... r{ <br /> -- ----- ----- ---- <br /> Final Inspection by:._, - - <br /> ��..- - '----------- -----;------- - ��------.....------- -- - -- ---- ------- -bate.- - Z--- -L- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 8.S 21677 REV. 7/76 3M <br />