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FOR OFFICE USE: ✓ y FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 01 (Complete in Triplicate) Permit <br /> ------------------- -----------------�---........------- 5 � <br /> -- No....7.�---��•-- <br /> Date Issued--/—./�"--�� F <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---- . - , .- ----------------STAN------------ ----•--_- ---..__CENSUS TRACT..........- ------.----- <br /> Owner's Name .. ------- ------------ -------- ---- ---­­----------------••- ----•--------------. .Phone.---- 34/Qa......... <br /> Address.......�� 5�3. ...cGlOt�[!!Ew City LDD !� � dContractor's Name---- ---9101V .......................License #-.a,W-33rfiv5 _ _ one---- --------- <br /> -----.. I <br /> Installation will serve: Residence'X Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other..... ........._......................... •. _ ! <br /> Number of living.units:....-d/.-7=--Number-of bedrooms--......Garbage Grinder.............Lot Size....-.f�Q � X /SAO <br /> Water Supply: Public System and name--------------------- ----- --------------- -- _------------------------------Private <br /> Character of soil to a`depth of�3'feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam [3 Clay Loam ❑ <br /> Hardpan E] f;AdobeX Fill Material--...-- ----If yes, type....................-. <br /> (Plot plan, showing size of lot, locat i onvof'sy stern in relation to wells, buildings„etc, must be placed on reverse side.) <br /> NEW .INSTALLATION: (No septic tank or11seepage pit permitted if publ•ic-sewer is-available within 200 feet,) <br /> 'A' r ! , 5`.F A/ <br /> PACKAGE TREATMENT - X-8'-? ----------- ----- Liquid Depth.-'-.`� -----....... <br /> Capacity'.-�aOO T e Maters <br /> ( ) SEPTIC TANK ( �EL�Size . . .��- 0 �l� No. .----------dl.. ----- <br /> Compartmentsi <br /> Distance to nearest:Well-'..........S_ ..... t <br /> ...!"o`undation... I ......._._.Prop. Line------- <br /> f Length of�each line..... ... �p <br /> LEACHING LINE (K"-No. of Lines'.,_:--..p�- ---- ---`-- g .. .. .........Total Length .....---------------------------------- <br /> 'D' Box..... ... ..Type Filter„Material..__-5R._.......Depth Filter Material_! ...... ... ----------- <br /> ,. r / / <br /> SU p Distance to nearest: Well_ .. p...........Foundation.....` ��..."�........Property Line......S-.................... <br /> y -_--Number-- ---.-•- ` Rock Filled YesNoIvy' Depth..--/0 .....Diameter_------_ - <br /> Water Table Dy Xa X/Cepth.------------------------ - ...... - ...............Rock Size.----.. t.. ......-----------........ <br /> ❑ <br /> �. <br /> Distance to nearest:'Well.........../-5.- -L- .........Foundation-----. -_/-.......Prop. Line ...4.... .......... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.................:.................................Date...°._.:.---------------- ----------) } <br /> Septic Tank (Specify Requirements).... ............ ----------------­----------­­.............. ......_----`. ----- ----- ....... <br /> Disposal Field (Specify Requirements) ............: ............. ............ - . .. �'---------- ------------.--- <br /> ��` ,' C <br /> ------------------------------------------------------- <br /> ------------------ -------------------------- ----- -- ------- <br /> = --------------- ...----- . - - -------I........----------- <br /> (Draw ezis'ting and'reiquirecl 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 subject to Workman's Compensation laws of California.” <br /> Signed-- .... --- - ------------------------ -----Owner <br /> BY _Title_._.......EST/./l't %:TdF�,................ <br /> (If other than owner) <br /> FOR EPART NT US ONLY <br /> APPLICATION ACCEPTED BY....... - .....-----DATE [ <br /> DIVISION OF LAND NUMBER.-- • -- ------------------ ... <br /> ...------......------...... ----DATE....... . ..... ---- ............ <br /> ADDITIONAL COMMENTS. ....... -------- --------------- -------------------- --------.. <br /> ---- -- <br /> ............................ ------------ ---- - ------------- ---------------------- -- ------ ---- ----------------------- -----_.... <br /> •--- •-------- . <br /> �.. ------ .. -- ----...- <br /> Final-Inspection by:......----- -- - ---- ------------------------------•- ------------- Date <br /> FBS 21677 REV. 7/76 3M <br /> - ��° ����C <br /> Eli is 24 SAN JOAQUIN LOCAL HEALTH`OISTRICT ll' <br /> . t <br />