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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERM, <br /> ................................................. <br /> (ComploN In Triplicate) <br /> Permit No...7. ...-/.3.0 q <br /> ......................................................... Date Issued..�..4t.1.".7/ <br /> .....-..._.......___.._..._..................__. This Permit Expires 1 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 <br /> �./........y.2.O.Q----- .1�0.-ck:..y..._P ...._.eco-txy4..__._....CENSUS TRACT...._....._..�..•._........_.._ �— <br /> owner's Name.--J.r.._,...1-'.�_0.8 ....t�. .....L............. -- __.-....._.. -._.-.._.. -.._-....__..............Phone...�3 :..tr..4.2�.... i <br /> Address..._U.-.�.-..l.........w,71 ..e.....'_�.` _...3.T._.....- .-._.... - .... .. .._.City ..T.f 54..S .V - - - Zip -953.I.L. -----o <br /> Contractor's Name._..k.�._._.►"�........C._.G 1.." rvC.-sem`.................. ___.:.License ..Phone._8Ll .[309_ 1e� <br /> Installation will serve: Residence*01. Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ r',Other......:...........Number of living units:......1........Number of bedroomV.S.. ..Garbage Grinder . Lot Size ...... ................................................... <br /> Water Supply: Public System and name---- ... ...]. ..---- -- ..... .._...............----------- ------------------------------------ Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ lay ❑ 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is ,) <br /> available within 200 feet <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size----I-20..d.__. %A __---Liquid Depth ....-------.....---.......0 <br /> Capacity.l2.o.0,jCType._.................. Compartments -..` -..,t�:..rr. .................� <br /> Distance to nearest:Well...C�- ..--__1-. .____-_._Foundation._.I.0_-.._..........Prop. Line_--9_-��./............ . <br /> LEACHING LINE O No. of Lines ...... 3................ Length of each line a Total Length .. Z90 ...................... <br /> .. .................... <br /> D' Box.._,......Type Filler Material.'.YL.K7Lkepih Filter Material----.-J.q <br /> Distance to nearest: Well.....I-(30.........-....-Foundation Property Line -...Sb./................. .. <br /> p ❑ <br /> SEEPAGE PIT ^(,� De th......:_.......Diameter._.....,..._.......Number_............... No <br /> Rock Filled Yes <br /> Water Table Depth-:--1---:------------ .---------------...Rock Size.-.. ................... ------------- <br /> Distance to nearest:'Well--------1............ ............. Foundation...................... ...Prop. Line........................... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................._.................... ------ Date.__.. ......................................) <br /> SepticTank (Specify Requirements)............... ...................... .............................. ............ ...............................11......... ....................... <br /> DisposalField (Specify Requirements)...................... ..................... .......... ........................................................................................... <br /> I <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 /> "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 becort,(�/e�4ub' ct `J'a Warrlkm �s Compensation law f_ C liforma." <br /> Signed J.1-'.. .....✓/L.`. - �:..�C1� ....-•.•Awner <br /> By........................._.......................................................................... .. Title... .. ._- __._........... ...... .............._ ........ <br /> (If other than owner) <br /> OR DEP TMENT SE ONLY <br /> APPLICATION ACCEPTED BY. _....... :. 2 .._...._..-........_..DATE .. <br /> DIVISION OF LAND NUMBER.._..--- ... ................................. ----__-......................................DATE ...... . .... <br /> COMMENTS...... .. . . . .... ............ ................... ..... .... ... . <br /> ­1­ <br /> ............................................................_..................­__............... ............_. - --------- ................. ............................ <br /> ----------------- - --- ------------------ --- ---- ----_..............._....._.. --------- -- ---------..----------------------------- ............. - - ........_...... <br /> .. . <br /> .................................................. <br /> Final Inspection by:_......._._.:-..---..._..._ .. ........_ _- �.-------------...____...............__.Date-_. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M <br /> C <br />