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f <br /> FOR OFFICE USE: , f FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------- ------------------------- I\ Permit No._17F-/�l�_� <br /> (Complete in Triplicate} <br /> 7ADate Issued/_a-._..S-._.,;� <br /> _____________________ This Permit Expires 1 Year From ate Issued <br /> Application is hereby made to the San Joaquin Local HealthilDistrict for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 519 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _/:.� - CENSUS TRACT----.-.-- == <br /> Oner' Name , -- ---- ------ --------------- ------- -------Phone-------------------------------------- <br /> Address ff W C� C�� .' �i <br /> 7' = -- -- ---- - -------------------- ------- - --- - City P <br /> Contractor's Name �'~ .�� % XT <br /> License #_ -_ _7__Phone_ <br /> — ,..�.L f--„c� -� rat <br /> Installation will serve: Residence X Apartment, H use.[] Commercial ❑ Trailer Court ❑ � <br /> ..: Mote! ❑ Other- - ---------- ----- ----- -------- ------- <br /> Number of living urfitJs _A1 'Number df-bedr om_s_E'_�_-.Garbage i der.W"°+ '_Lot Size_____ ______ ---- -------------------------- <br /> witR ��, r I, T I <br /> er Supply: Publiesystem and name-- - ------- ---------------------------------------------------- ---- -- Private ❑ <br /> e <br /> 1. <br /> Character of soil to a depth of 3 feet: Sand E] Silt ElClay ❑ Peat ❑F Sandy Loam ❑ Clay Loam El r' <br /> Hardpan ❑ Adobe Fill Material-_.._'__.---If yes,,.type-------------------------------- <br /> (Plot,p_lan, showing size of lot, location of system in relation to wells, buirdini3s, etc, must be placed on reverse side) I v <br /> NEYV-INSTALLATION.__fM5-sepfic`t66V r seepage pit permiffed if public,sewer is available within 200 feet,] <br /> PACKAGE TREATMENT ] SEPTIC TANK X Size--- _ _ '._f ___ 0-___-___.-__-_--Liquid Depth.-! 1 f o. Compartments 1 <br /> Copaatyl `' 'lTYPe L � Material__ --.e� N p ------ <br /> ��.. Distance #o nearest: Well. _ __Foundation_.__ _.f___-.____.Prop. Line__.____.___�____ _ <br /> ----- -- <br /> LEACWING LINE; Na. of nes__ _ ._. �`Length of each line �1.. __-Total Length _.__---4'7 __--------------- <br /> y <br /> ___ _- i <br /> i <br /> D' Box.--�---- Type F11ter Material_. _.Depth;Filter Material. .---____- -------------------- <br /> �epih.&S <br /> istances to nearAt: Well. .04 C-_.Foundatior ._ '_.-.__ _--__Property Line _._",`�_'_.___.. <br /> SEEPAGE PIT _____._Diameter___ _ _ ______Number__'_`_ __________ Rock Filled Yes No ❑ <br /> 4 r Water Table Depth ."�' r ( Rock Size --- - ----= __ <br /> V; ------------------------------ ------. dation-- ----• p I <br /> t Distance to•neorest: Well.._C -- le- - ----- -- Propr Line---4Z--------------- --- <br /> REPAIR/ADDITION�Prev`''Sanitation Permit# � -!.Date--. ] � i <br /> Septic Tank (Specify,Requirements)-.-------------------- -:----------------------,. ; <br /> Disposal Field (Specify Requirements)-------- �------ -------- ---- ------------=------------------------------------------------------------------------------ <br /> __________; --------------------- <br /> _._______.________.________.____..__._______.____.___________._________________________ <br /> _________________________________________________________________________________________________________________________________________________________________________________________________________________ <br /> (Draw existing and"requi'r`ed adcli"ti6-n-6 n reverse sidel­ <br /> I hereby certify that I have prepared this,appi i cation 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 /> signatue 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 /> I <br /> - f <br /> CLAREI`,�F s" SEPEG.0 � S�lvi=R �...P`JIC <br /> Signed---- ------------.Owner 263 5�. 0°.1 5toukt:o p, "a'if. S5'�5 <br /> IY <br /> y ------------ ------------T t ---- --- - <br /> (If other than owner) 1�y t <br /> r F DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY- -- ---------------------------------- ----DATE... ---------'i---------- <br /> DIVISION OF LAND NUMBER-------------------- ---.DATE-------------------------------- <br /> ADDITIONALCOMMENTS--------------------------------------------- ------------------------------------------------------------------------------------- ----------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------------------------------- ..-- ----------------------------------------------------------------------------------------------------- ----------------------------------------------- <br /> Final Inspection by:_----------- ...... - <br /> ----------------------------------------- ----- --------:---Date.---Ca-- ;;�__,7� ----------------- <br /> EH <br /> --- --- -... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fns 21677 REV. 7/76 San <br />