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FOR OFFICE USE: 4/ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------•-------------------•--•---- --------- - Permit No.78���$�3 <br /> (Complete in Triplicate) <br /> ......................................................... This Permit Expires 1 Year From Date Issued Date <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.. ..r�.Qa .! 'L 6 - 91./..........................- ----•---CENSUS TRACT.-- ------................-1! <br /> Owner's NornKr4C-d.6...._W1 M _rr. .............................................................. ..............Phone f—'G <br /> e <br /> . / -.......... Cityl .................zip-�Ae7r.: .37--.-_ <br /> - <br /> Address----- -�---/------- - ..... <br /> Contractor's Name. ._ A4 7—AI_.....oo.9_ooW ,..a✓lYt- ... `Litense # %� K�I�I 3 Phone.-T4. !l!r <br /> Installation will serve: Residence X Apartment House❑ Commercial Eg.`Trailer Court ❑ <br /> Motel ❑ Other... ------------------------- <br /> Number of living units:....—--------- of bedrooms...73.__Garbage Grinder.__-:_ ..__Lot Size_ W/z._... t ------------------- <br /> Water Supply: Public System and name........................................:...•---- -------•--'-A--- ------------•----•-------•- ----------Private ('g, <br /> -Cfiaracter of soil to a depth of 3 feet: Sand [] Silt❑ Clay ❑ Peat Ej '.Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ 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 seepage pit permitted if public sewer i!available within 200 feet,) <br /> PACKAGE TREATMENT [ J SEPTIC TANK ] Size_/020.4a. --. ---_--_Liquid Depth ... ... V <br /> Capacityfa�9 -----TYPe-----------------------Material--------- -. . No. Compartments r2......- <br /> Distance to nearest: Well.. _/00.____..................Founda.tion......�d.....-.__. --Prop. Line._.--_. -------- ........ <br /> r <br /> LEACHING LINE [ J No. of Lines.......4----.............Length of each lina......6 '..-............Total Length ..1-7C__._ _................. <br /> 'D' Box....I.......Type Filter Material p..lWrsLDepth Filter Material------l9.i................................................. <br /> Distance to nearest: Well..-1D .,._..._. Foundation... _�___. __....Property Line........... ..._..__----.___..__. <br /> SEEPAGE PIT [ J Depth._ 5------Diameter- - ..3�.-...,',Number.........�L....__............ Rock Filled Yes.0 No❑ <br /> Water Table Depth....................:......._.. ---•--. ---Rock Size_.//A--- f..---... -- --- - - ...-------- <br /> Distance to nearest: Well...l-��--.....`....— __.__-. --.---Foundation..__J,04............P rop. Line.-.._-----___--_---.._.-. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.....__ . ___ _-----------------Date-------------------_---- <br /> Septic <br /> ............. <br /> Septic Tank (Specify Requirements)--- ---------- - ---- - ----- ----------- - .----------•--•-------_ ---~------------ ---- -- ---------- ------------------- <br /> Disposal <br /> -- -------.Disposal Field (Specify Requirements)---------- ------- - ...................... ....... ----••----------- ------------ -------------------- ----------------- <br /> - -- ..... ...................................... <br /> .....................................-............................1__A-...._..........---...------.-._a-'--------------.-....-.----- ----- - <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 work for which this permit is issued, I shall not employ any person in such manner as <br /> to becoml,,pblect to W rkrpan's Compensation laws of California." <br /> Signed- - -......... ............. .... - -••--• ----- _ __ ....... <br /> By-- ............................•-------------.•--....-..---••-----------.-------------- --- -- _.Title.--------- ---- . ....... . ------ . ----•------ -- <br /> (If other than owner) <br /> R DJZPARTMT �OY �� <br /> -------- -- - -r• - :;:: .T J,--= <br /> -' <br /> .--••--- ... <br /> ��' ---------DATE_./. ................-APPLICATION ACCEPTED BY . � ... _ <br /> ----- DATE........ . ._...DIVISION OF LAND NUMBER-- --- -------- ---- - -- - ------ 1 ..... ....-------•----- ------ - -- ------- -------- <br /> ADDITIONAL COMMENTS- - - ---•-,---------------------------------(*.­­_*"­7 <br /> -- ----- ----.-..----------------------------.-.------•-----------.--. ................. <br /> -----------------------------------------------------*------------------------------------ <br /> .......... <br /> --------------------------- ........ <br /> ............................. . ............. ........*....... <br /> `..- <br /> - ------------------------------------------ - ................ <br /> .............................................. <br /> .................DateFinal Inspection by: - <br /> .---_.....--------------- ------------------- ._ ...... ..................._..........._._......• .................... ....... _ .................... <br /> EH-13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F6 21677 REV.7/76 3M <br />