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FOR OFFICE USE: FOR OFFICE USE: <br /> —13PLICATION FOR SANITATION PERMIT <br /> ------------ ---------------------------------- —5 / <br /> (Complete in Triplicate) Permit No..._<...___.-.._.._q <br /> - -------------------------------- Date Issued.. <br /> . .____....._....................._.__._._..-___ This Permit Expires 1 Year From Date Issued <br /> a: <br /> F plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> T s application is made in compliance with County Or nce No. 549 and isting Rules and Regulations: <br /> JOB ADDRESS/LOCAT N_.. - ----- - ----- D`/le<C.---- ---------------------------------------CENSUS TRACT-.---- --- - <br /> �f <br /> vner's Name.- -- -- -- r� 'j- -------­--------_-----------_--- ---- ----- <br /> 00, - hone 7oZ�—� yAddress 177---- - -------- -------------City 444/------...------Zip- <br /> ---------------------------- <br /> ntractor's Name----`��� -------- --License �f. C�`5_�••?/--- -495:Fgi <br /> tallation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------------------------------- <br /> imber of living units:_ ___-- ..._Number of bedrooms_,.�3_.---Garbage Grinder..__.-------Lot Size--------- ... _--dam_-_________________________ <br /> ater Supply: Public System and name------------------ ----------- ---- -------------------------------------------------------- ------------------------------Private. <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Fe� JZ <br /> Hardpan ❑ Adobe ❑ Fill Material__ -----.---If yes, type-------..............__._._.__ <br /> (Plot plan, showin size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> ,i <br /> :W INSTALLATIO,N: :� (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> kCKAGE TREATMENT , r ] . SEPTIC TANK �'� a'StY�: _SZas_.e _S'-��� iquid Depth _----------_-- <br /> D� 2-'------------------------- <br /> Ca,�aaty-�e�__._.._...___Type___ _ _ _ ____..Material._.___C._O_��._._,.No. compartments_..__... <br /> r ry r <br /> Distance to nearest: Well_..__.��-___________________________Foundation..k-I0_________.._-__Prop. Line.-._/-�s._._-..-..-.__-_. <br /> LEACHING LINE ['� No, Aof Lines_ g 1 <br /> -----------------------Len Length of each line._-- ---------------- Total Length _---��rV_...____.----.-___.-- <br /> `/p v/�1M ? I <br /> D° j4 `_.__._Type'f Ater Materig(`1' �._ ....Depth Filter Mater al . ______.. ___. <br /> Distance to nearqst:J/�/et1_:_f 1�.. Foundation :_. � � ,._,�Property Line...l U .__ __ <br /> SEEPAGE PIT [ ] Depth--c ._._.Diameter'::_----------Num-ber Rock Filled Yes.� Y �' No ❑ <br /> Water Table Depth. l -----•-----"._.•- - ------.Rock Sizes- -------- --------------- <br /> Distance to nearest: Well _--. _____________ ________fokndation._____ .__.____.,._ Prop. Lipe------------------­----- <br /> ------ _ <br /> i <br /> _. <br /> :PAIR/ADDITION (Prev. Sanitation Permit#------------ --------------------------------------Date---- -- --`= _•... :-------`----_------) g.. <br /> )ptic Tank (Specify Requirements).......................__-- w I <br /> Disposal Field (Specify Requirements)...................... ..... ----------------------------------- <br /> ------------------------------------------- --------------------------------------------------- ------------- -------------------------------•------------------------------------------------------- --------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ,.rdinances, 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 /> .J become subject to Workman's Compensation laws of California." <br /> Signed------------------ ._.. - x - --- ----- --------- ---- ------.--Owner /✓� <br /> iY Title DGcJ K�__V.. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> kPPLICATION ACCEPTED BY-----r. .. U-2-fc�,�--- ------- -------- -----------------DATE ----- - - <br /> DIVISIONOF LAND NUMBER.-------------- . --- ---------...-- ------------------------- -------- ---------------------------DATE....-------------...:-------------------------- <br /> \DDITIONAL COMMENTS----------------- -- ------------------------- -------------------------------------- ---- --------------------------------------- -------------------- --------- -- <br /> ------I----­ <br /> ------------- ------------------ ---------- ----- -------------------...------------- ----------------------------------------------------- -------------- - ----- ---_---------- ------- <br /> ---------------- -------------------­-- --------- ------------------------------------- - ------------------------------ -- ----------------------------------- --- -------- --------------- <br /> --- ---- . – <br /> r . <br /> - -------------- <br /> sinal Inspection by:. --- ---� --- -- . --- --- -... Date <br /> M 13 24 SA JO QUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />