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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT G—!00,7 <br /> -•---------------------------------••----•-- Permit No...7- ----••------ <br /> (Complete In Triplicate) <br /> -------------------------------I------- _- - 7<- <br /> .................................... <br /> G <br /> Date 155L[ed....�':..-•------.•._. <br /> ..........._........................................... This Permit Expires 1 Year From Date Issued <br /> 0 0 �-1�✓va a%J4_ r 17 v -40.3 <br /> Application is hereby made to the San Joaquin Local Health District for a perJ4toconstruct and install the work herein described. <br /> This application is made in compliant with County Ordinance No.549 and existing Rules and Regulations: <br /> : 7LJ <br /> JOBADDRESS/LOCATION.__....... w..•�........---------••-----•-......................_----.:.........__.CENSUS TRACT.............................. <br /> Owner's Name.--.-- • - -•----- ----- -_. ........ - - ------------­----------- .. ... _ Phone................ . ....._.... <br /> '.. zip.- <br /> _ I <br />. Address--/ ... . ......... .. . _.............._.. .... -- City.. <br /> ._... F'•' <br /> Contractor's Name---- -- . -'-.,_ - -- _• .. .. ............-•___-4 ------=Wit_-•,-----License # Phone. <br /> Jr <br /> Installation will serve: /Residence ❑ Apartment Hou Co mercial ❑ Trailer Court ❑ " <br /> f 11 I Motel ❑ Other / <br /> t -- + , <br /> Number of living units ..... Number of bedrooms------------Garbage Grinder..........,.Lot Size 4�-5D. . <br /> WaterSupply: Public Systema d name_--}............ ................ ................................................ ................ --------:--- •----------.-..Priv+. <br /> ! A. r I <br /> Character of soil to a depth of 3 feet: -Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam E] Clay Loam ❑ <br /> ,Hardpan ❑ AdobeA Fill Material..........--If yes,type________________________________ <br /> (Plot plan,#.shcswingsizerof lot, location-of system in relation to wells, buildings,etc, must be placed on reverse side.) o <br /> NEW INSIA�LLATIOIV: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> 0 <br /> PACKAGE TREATMENT [ I SEPTIC TANK Size_ __________________ -.-Liquid Depth..'.................. <br /> Ca acct Com__ . T e_ .___ , Matenal_��'�--_..__._No. Compartments.._.•.n __..... <br /> Distance to nearest: WeIL., Q.........................Found ti:4eotal <br /> --------------Prop. Line._�3..._�^' i'.Lb <br /> 11 <br /> LEACHING LINE ( No. of Lines.........!...................Length of each line.- Length-. .. � !__.� <br /> 'D' box..........._Type Filter Material_Se_/V epth Filter Material-____/,?.,. <br /> f f <br /> ` Distance to nearest: Well.f.hi2/..........Foundation._.._.9_..............Property Line__.. ____._..___._.______�' <br /> a <br /> SEEPAGE PIT ( ] Depth----------------Diameter_...................Number................................ Rock Filled Yes❑ No[ <br /> WaterTable Depth---------------..........................................Rock Size---.-------...-•---------••-•------------•------ <br /> Distance to nearest: Well...----------------------------------------Foundation..........................Prop. Line...___-------n <br /> REPAIR/ADDITION (Prev.-Sanitation Permit#...................................................Date..........................:-.................. <br /> ) <br /> fSeptic Tank (Specify Requirements).................................................................. -----•--- -------------------• ...................................---------- ......, <br /> DisposalField (Specify Requirements)...................... ...............---- ------------------------------------••---------------------------------------------------------------------- <br /> - <br /> ..............---------------­----- •.... <br /> ................... .........................................................--------------------- ......----•--......, ---..... ....................................... <br /> _.C�.. <br /> (Qraw 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, Nome owner or licensed agents <br /> signature certifies the Fallowing: <br /> "I certify that in the performance of the work for which-this pernilt is Issued,) shall not employ any person in such manner as <br /> to became lec to k an's ampensation laws of Callfornla." a <br /> C <br /> Signed �t = Owner < <br /> By..............•---- r r .-. - _-----.........Title._....._ .. .�------•----........._ .. _.---.......------......-.---. <br /> (If-other th n owrier} <br /> try FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B -._ -_-_ eEek ... ... ------------==-•-•---------•-•---------------DATE_Ac.� .:e�T ._....---------------._.-. <br /> DIVISION OF LANDER.. ............. •-•-- . ---•....-----•......DATE........... -------------------------------- <br /> ADDITIONALCOMMENTS------------------ ........... .................•-----_.............__._. ................................................ ....-----•----.-----•-•--•-----_ <br /> ------ ---- ---- <br /> -- - ---------• --------- --- .__.................-•---. <br /> ------------------------------- -----..---.---------..................... :---..-..-•---..-.---_------- � <br /> ..............I-. ----------•-••-..... .... -- --- --------------- <br /> --......._...........----•-----•-- tales <br /> Final Inspection by: ------------------ Da _._.... <br /> e+ 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV-7/76 3M <br />