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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> (Complete in Triplicate) <br /> Permit <br /> Date Issued__-.//-_72 <br /> --•---------------------------------------------------- This Perrgi"xpiresY�Tftm Date Issu <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._-_ . Y -----------------------------------------------------041 G- A0T _�-_�� -�_�___CENSUS TRACT-.._..-_-______---_--_.___. <br /> /f <br /> Owner's Name------ --------Ae w------ ---17-%seY----------------------------- ------------------------------------------------------Phone---- --------------------------------- <br /> Address----------------56g/i1'e-- --------------------- <br /> ------ ------------------------- ----- -- ---- City------ - ---------------- ----- ---- -Zi <br /> Contractor's Name_______ _`7 r�J_s44 -f__-------V---_--------------- ---- --- ----License #_Z0X-.��G____.Phone_-A rZ?L_�_ <br /> Installation will serve: Residence Iff Apartment House❑ Commercial ❑ Trailer Court ❑ 4*1 <br /> Motel ❑ Other--------------------------- <br /> Number of living units-----------------Number of bedrooms.-----------Garbage Grinder--------.---Lot Size----------------------------------------------_----------_ N <br /> Water Supply: Public System and name----- - ------ r_._ —1---------------------- ----------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: S' nd ❑ Silt F] Clay E] Peat EJSangy Loam F] Clay Loam ❑ <br /> Hardpan E] A obe❑ Fill Material_---- ----If yes, type__ -------_________---________ <br /> y <br /> (Plot plan, showing size of lot, location o system in relation lls, buildings, etc.imust be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage ermitted if public sewer ils available within 200 feet,) -, <br /> PACKAGE TREATMENT [ ] SEPTIC TA K [ ] Size-------------------------------.i ------------Liquid Depth.______-.._________._--- <br /> - <br /> Capacity-.-/iZO- _ yP p�-4�tT �-_______-No. Compartments----�-r-=----- <br /> _T e__-__-_-- Material-- __-' <br /> -------------- <br /> Distance to nearest: Well____________________________----_-__________--Fou-nXda 'on-_-_LP�--------------' , <br /> Prop%.4Ldine_-S�"*-.__--- <br /> _______---. <br /> n 'LEACHING LINE No. of Lines------- ---------------------Length of epch line.Ap_-- _..___Total Len --_______. <br /> � / th <br /> /,1Tex AFe/ 'D' Box_______-___TJpe Filter Material__O°C�'_------Depth FilterMaterial---------------------------------------------------------------- <br /> t_� <br /> Distance,to nearest: Wel(V�.__ -_...-____..__Foundatio- n._` 'vr -------------Property Line----- <br /> ------------------------------- <br /> SEEPAGE <br /> ____b_--_____-_________ _h <br /> SEEPAGE PIT [ ] Depth-----------.----Diameter----- _\ ---------Number-------------------------------- Rock Filled Yes ❑ No ❑ S_ <br /> Water Table Depth------------ x Rock Size-- <br /> Distance to nearest: Well---- <br /> --------------.------Foundation--------------------------Prop, Line----------------------------- <br /> ' r <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--._______ ---------------------------Date___..________________'_--___________-__.___) <br /> Septic Tank (SpecifyRequirements)----------------------------1------ i--------- ------------ _ <br /> - ------------------------------------------------------------- <br /> Disposal Field (Specify Requirements)------------------------ - --------------------------------------------------------------------------------------------------- <br /> -----------•-------------------- ------------------------------------------ <br /> __- <br /> (Draw existing cfnd required�gdo,if+on ori reverse side) <br /> I hereby certify that I have prepared this application and that thw-work willi be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and R9juic io4_ol~_.the-Barr- wquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: i <br /> r <br /> "I certify that in the performance of the work fo;� which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensatior4 lavas of California." <br /> vOwner <br /> y- :_D - <br /> _Signed----- <br /> By------ <br /> --- <br /> BY------ ------ <br /> ---- <br /> --- r -- - --) ------ � - Title <br /> an owner <br /> . .. P <br /> APPLICATION ACCEPTED BY-- = ?jL� DATE. <br /> DIVISIONOF LAND NUMBER - ----------------- ------------------------------------------------- -----DATE----------------------------------------------- <br /> ADDITIONAL COMMENTS---------------------------------= <br /> - -- ----------------------------------------------------------------------------------------------- <br /> ------ -------------- ----- - ---- ... ----- <br /> ---- - - <br /> Final Inspection by: f- -- --- -- Date ..._ <br /> EH 13 24 JOAQUIN LOCAL HEALTH DISTRICT F, 677 REV. 7/76 3M <br /> f`�r/A <br />