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FOR OFFICE USE: e FOR OFFICE USE: <br /> ..r APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No...7_.-'... ._.-. <br /> _----------------------------- ----- <br /> Date Issued-.�--- ---------- <br /> ...................... ..... ... ............. This Permit Expires 1 Year From Date Issued <br /> kpplication is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described, <br /> is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION------- _ <br /> ."L"l.E'- .�./.._.77-_, ,tl. .'...-. ._.._..-- -----•-----------------------.CENSUS TRACT.-------••-------- --- <br /> vner's Name ..- . ..- -... .._ - ----- .. .. _ ---- ---------- •. •---------- ---------- _.Phone.-------------•-- --•---...... . <br /> -*Jdress---..---- -. . Cit ----- <br /> Contractor's Name._-_--_ .-� �. _ _.--.-_-..-_-.License #.W-7-J-71 __Phone_ - <br /> stallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other........ _ . ---- ------------------------ <br /> imber of living units;.......I-------Number of bedrooms-----L f Garbage Grinder------------Lot Size--_-----. ---- <br /> , ,ter Supply: Public System and name-- ---- ------------------------ -------------.---------------------Private F. <br /> -haracter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ 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 /> "W INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} O <br /> .�CKAGE TREATMENT [ ] SEPTIC TANK [ �.-Q---------------------Liquid Depth..- -- <br /> [ l Size -. T �---��(,- -------------------- <br /> Capacity-16jRV----Type- __4------ ...-,-Material---11_! `- , - ----------No. Compartments.---�_-----__- �E <br /> Distance to nearest: Well..................... ...... ...._.....--.Foundation----.--._ . .-.. . .- .. Prop. Line_---------.__._.__-1 <br /> EACHING LINE [ ] No. of Lines 1,3--.--___--__-.----Length of each line......L t --------------- Total Length ./ <br /> 'D' Box--'.... -.Type Filter Material..-/_ Depth Filter Material...--...... ------------- <br /> .. Distance to nearest: Well-----------I_ ........Foundation----------------------------Property Line----._----__- _ . <br /> iEEPAGE PIT <br /> [ ] Depth_-. -.b-_-Diameter -t :.._-.Number_ _-_- _- Rock Filled Yes No(1 <br /> Water Table Depth-------------------- .......... .........................Rock Size-- - h._. <br /> Distance to nearest: Well.... ...$.0_-------- ------- ----Foundation..... . ........ ...Prop. Line------------------ <br /> __- <br /> --PAIR/ADDITION <br /> (Prev. Sanitation Permit#--------------------_---...._.._. .._.-----------Date---.-_..........._.._...-._-..-._-..---..-.--_) <br /> tic Tank (Specify Requirements) ------------------------------------ -- ----- <br /> Disposal Field (Specify Requirements)-------._------------- ------- ------ -------- <br /> ---•----------- ----------- - - ---------------•---•------------- ----•- -------------------------------------------------------------_----------.......-..--- -- <br /> •----• --------------- -------_- ------ . ----.... -------- . <br /> (Draw existing and required addition on reverse side) <br /> iereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> Trdinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licensed agent <br /> signature certifies the following: <br /> certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner a <br /> 'o become subject to Workman's Compensation laws of California." <br /> ;:3ned �ower'j­ <br /> JFOR <br /> ---------------_----- ----Owner 4A <br /> . '.•--•-•-•-,-- -.`�-..- - - - -tthe)r� <br /> - ----- - Title.. - -- -------------Ifthan nDE RTMENT USE NLY <br /> fIPPLICATION ACCEPTED BY -DATE --....- ......._.-.. <br /> DIVISION OF LAND NUMBER... -----.... ._._ .- . ..._. DATE. <br /> DDITIONAL COMMENTS--- ------- -- -- --- -- - - ------------- _.... ..... ... <br /> ---------------- ------ -------------------- o <br /> ------ <br /> �`' '✓ - <br /> G - - �,�-- <br /> _nal Inspection by:-----7- � Date — .. ... . <br /> EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3 <br />