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FOR OFFICE USE: FOR OFFICE USL: <br /> V/ APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit NOX ...... ........ <br /> ----------------•------•- ----- - - .....- -.....----- Date Issuedl0-�T-/l:_70 <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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ----------- - - --3 -v!//�!.�. /Li! E a-a.-- •-----..__...-----------.....---.CENSUS TRACT._..-------------- --- ---- <br /> Owner's Name.... ...... a'.Jvk......../. .r/��� J Phone ----- ----------- <br /> Address------ <br /> ----- ---Address------ r Zi <br /> g ------..... City--------------- { :3 �. p........ -• ----...---........ <br /> Contractor's Name.................. <br /> Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> i <br /> Motel F-1 Other---- -- --- ------ --------------------- <br /> Number of living units:-...I'-/.----_---Number of bedrooms...-. . Garbage Grinder._.---------Lot Size--_.--- ...... <br /> Water Supply: Public System and name.. ......._.. 1���. �"� .Private <br /> pP Y Y �� ..... ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Ki 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 /> PACKAGE TREATMENT ( j SEPTIC TANK [ ] Size .. _. . - - - --------------------- ----------.--"_Liquid Depth..•--..............--.--- <br /> Capacity...... ....... <br /> ...-- Type--- Material---------- No. Compartments.....................__........ <br /> � <br /> Distance to nearest: Well---_------- ..... .... .........Foundation--.--_- - - - Prop. Line............------.-----_.. <br /> LEACHING LINE ( ] No. of Lines __.-.--.-_.Length of eachlino.............................. Total Length -. ----------------------- <br /> 'D' Box-........ ..Type Filter Material........ ..... .....Depth Filter Material.......................... .........._-......................... <br /> Distance to nearest: Well------------------ -- ------Foundation -------------- ------Property Line----------....._------ -- <br /> SEEPAGE PIT [ ] Depth.... _ -,,..Diameter---------------- ...Number-------------------------------- Rack Filled Yes ❑ No <br /> Water Table Depth------------------------------- ------- -----------------Rock Size..............------ <br /> Distance to nearest: Well.-................ .... . ................Foundation.._.._................._.Prop, Line...... <br /> .---------- -- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-_..__.._.._._. . ............Date....................... ------- ---_-----) <br /> Septic Tank (Specify Requirements)_____ --------------------------------- <br /> Disposal Field (Specify Requirements).... (iC 1 C.1S...F... !.(__7 h!". �- •--- -- ----178f <br /> le { <br /> --- --- <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 /> "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 s ct to r an's Compensation laws of California." T <br /> Signed.--- �. ------. Owner <br /> BY ------------- ------ Title ._.M , _ 1C <br /> (If other than owner) <br /> F DEPARTMIENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE . - l� . <br /> - - <br /> --- --- -------- <br /> DIVISION OF LAND NUMB -------- .._.DA ----- -. :. <br /> ADDITIONAL COMMENTS. ------ - ----- <br /> ------------- <br /> --- - <br /> ------------ ....... ... .......... .... .. �.. . ----------------------- --- -- ------ ...---- ...----?/�-"---------------------•----._` ............ .4 -----_-- ..__... <br /> _________ _______ _____ .. _ _ - . <br /> Final Inspection by:_.... -- --- ------------------------------------ - ---------------- ---- - ­1­.......... ._Date. L :.. .."jf .. ----- - ----- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />