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FOR OFFICE USE: 4 FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -' - <br /> Permit-�- No.Z_7-S-Z <br /> (Complete in Triplicate)--'-'- ---------------------------'----- <br /> Date Issued---7'�7-2 <br /> ...........-__-_...._......_...__.._...._.___ This Permit Expires I Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and inst� w�k heed. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regul i LL i <br /> [_- -Q- [ LZA <br /> JOB ADDRESS/LOCATION..__Aj0I. <br /> D.A - _ -----..--------------------------------CENSUS TRACT---------------------- <br /> Owner's Name.......__-- -------- 4 --- -r <br /> ✓f�fll 3 ------- -- ------------ --- ----- ----- ---------Phone----ieoe 40, ---- <br /> Address-----------------------f ea Z-1/1 RlZ --d4fiTi.�-------- ----' Zi <br /> p--------------------- <br /> P � ,_ ri <br /> Contractor's Name..-___.._ [.14 .- -_/ .E 4iL. .LV___ J? 4--;t(d,_License # Z .-._-Phone---+g6Y60,7_-_. <br /> Installation will serve: Residence Apartment House,,❑ Cclmmercial ❑ Trailer Court ❑ <br /> Y Motel ❑ Other:. - <br /> Number of living units:__ --- Number of bedrooms.... ...... g Grinder........-.--Lot Size---- _-. > -�_ V---------.._..__ <br /> Water Supply: Public System and name._.......- ._---- �'Cmrba e ----- Yncly <br /> 1------- --�- -- ----- -------Private ❑-- <br /> Character of soil to a depth of 3'feet: Sand ❑ Silt❑ Clay ( -Peat(❑ Loam ❑ Clay Loam ❑' <br /> Hardpan ❑ Adobeo" 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.) <J <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted'if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ) Size_------------------- ---- - --------------------------Liquid Depth__.--.-_..-.---------.- <br /> Capacity--------------------Type--------- ------------Material ------------------------No. Compartments---------------------------------- <br /> Distance to nearest: Well---------------:---------------------------Foundation----------.--------- -----Prop. Line-----.---_---.---..------sr( <br /> LEACHING LINE [ ] No. of Lines---------------------------- Length of each line_ --------------------------Total Length __ ------__----------.. _----_-.-0 <br /> 'D' Box- -Type Filter Material Depth Filter Material--------------------------------_-------_----------------�. <br /> Distance to nearest: Well_-_----- -----______Foundation-----------------.----------.Property Line-----------------------------------I <br /> SEEPAGE PIT [ ] Depth---- ----- -----Diary*ter_------------- ....Number___........_- ..._-------_. Rock Filled Yes❑ No❑ <br /> WaterTable Depth-------------------------- ------ - --------'----------Rock Size---------------------- -------- --------------- <br /> Distance to nearest: Well_ ------- --------------------------------Foundation--------_.___---------Prop. Line. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------_------Date__----------------------------------- -_--- <br /> E r <br /> Septic Tank (Specify Requirements)---- - - ------' ------------------------- -�-----------------------------�- � � <br /> Disposal Field (Specify Requirements)-'--�"- --`-�--- ---- --------------------- ----- ------ ------- `4�-- .�.r.-r�-----'' ??Q-- -"-- ',r--"_--'._`..-.-- . <br /> ------------------­­ ------------------------------------------`CJ--.�J <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 /> "I certify that in the perfor nce of the work for which this p rmlt is issued, I shall not employ any person in such manner as <br /> to become subject n's Compen laws o al ornia." <br /> Signed----- ---4& �iL i- - - ---Owner �L <br /> BY---------------------------- ----------------- --- ------✓ 7....---..Title--- RG_r..-- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- <br /> -------- ------------------------------------DATE ----- <br /> DIVISION <br /> ---DIVISION OF LAND NUMBER. ---- ---------------------------------_--------------------------------------------- DATE------- --------- --------------- <br /> ADDITIONALCOMMENTS.-------- --- ----------' - ----------------- --------------------------------------------------------------- ------------------ -- ----------------------- <br /> ..... ....-- .. -._-------------------------------- '---- --------------------------'--' ---- '- -------------------- ----- ------------------------------------------------------ <br /> --------------------------- - " - <br /> - <br /> ----------------------------- ---------------- ------ ------------------ ---- - <br /> .. J <br /> Final Inspection by:.------ -- -------- -------- - ` - ----- <br /> -�----- - - - ------ - -- --------'--"-----.Date..--------- <br /> EH <br /> 13�� SAN JOAQUIN LOCAL HEALTH DISTRICT ras 2r REV.7/76 3M <br />