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FOR OFFICE U5 FOR OFFICE USE: <br /> s �� ,ley q APPLICATION FOR SANITATION PERMIT R <br /> Permit No.l.-1_.A.A_ <br /> (Complete in Triplicate) <br /> Date Issued_,l_7,7).1?-.-7p <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 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 ?. LIG... �//(/- �L��� K.S'------ ----- -------------- ..............CENSUS TRACT..-.--.-----------......... <br /> Owner's Name JGY C.5.. Q+^1.�r.. - ---- -•---------Phone.. - - --=--..:. <br /> Address ......... :....... c� vh_.P_...... City.__.GclL Q`4--._.................Zip---=- ------- <br /> ......:........................... <br /> Contractor's Name -------------- ..C'_l.f.......... .............. License #----------- -----..:...... -Phone........... ----- . <br /> .Installation will,serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel.❑ Other..... ... ........ -------------------- <br /> Number of living units:...... ---_.:_-Number of bedrooms- -- ,- -Garbage Grinder---..........Lot Size..................... ..---._.. .. .... .. <br /> Water Supply: Public System and name.............------------••--- -----...... ----------- ---- ---------.._....-_... - --.....----------------...'-Private <br /> Character of soil to a depth of 3-feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam & " Clay Loam EJ <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 is available within 200 feet,) <br /> r- , }Capacity....-- -- - -----Ty e......... .......... Material_._------ ......No. Compartments... -- .......- < <br /> A KAGE <br /> TREATMENT [ ] SEPTIC TANK [ ] Size_ - -------- --------------------------•- <br /> _ .__-__-. .. Liquid Depth_,"­', ` <br /> ti Distance to:nearest: Well.. -----•-- . ... ........ -.Foundation-.-_. :- Prop. Line__......_....... ••.S . <br /> LEACHING LINE [ ] No. of Lines --- - -----. ----.--. Length of each line:------------------------------- Total Length --------------- <br /> .D, Box Type Filter Material------ - - - - ---- Depth Filter Material --- •--•- ..._.:-- -- -.":.. <br /> Distance to nearest: Well..................... - Foundation_:.---•.- ...Property Line.....................---......I..... <br /> SEEPAGE PIT [,]. Depth -, ..----_....,Diameter--------------------Number- ------------------------ Rock Filled Yes ❑ No.❑P <br /> Water Table Depth.:------------- ---- :.. - ...........Rock Size '.- ....., .._.. -------------------- <br /> Distance <br /> - ------Distance to nearest: Well------------------------.------ -----------Foundation .............-.Prop. Line..----....._---. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------- -- ----- ---------------Date....---.--_--:.------- .---......:----.------] <br /> Septic Tank (Specify Requirements). -- -- --- -- <br /> Disposal Fi Id IS ecify Requirements)....... ef L--._.9.-0.'..� .. ------ a -`- _�`'^ <br /> •-----....... - $ , r. ... ----------- ----------- ----- - ........ <br /> -------- - -=--- - _ - ------ ------- <br /> -------- -------------------- ------------------------- - .: <br /> �:. [Draw existing and.requ•sred 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become suffiect to WorkmZ­ 's_Cam'enation laws of California." <br /> Signed--' ------------ - ...... <br /> ....... <br /> -- .Owner <br /> t. <br /> By............ ------ ------------ --_--------------___------------------------ Title.--- -----_---------... .... .................... <br /> (if other than owner) <br /> FOR--DEPARTMENT VU ONLY <br /> APPLICATION ACCEPTED BY -DATE ..- /4 7.............: l <br /> DIVISION OF LAND NUMBER......... ------- ------- ---------- DATE. ... --- -------- ---- <br /> ADDITIONAL COMMENTS......... ............... ------------ ----------------- ........ <br /> --------------- <br /> nal InsR2ction by:..... ....... ....Date_--- ! <br /> \3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT. Fas 2167y.REV. 7/76 3M <br />