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FCR OFFICE USE: FOR OFFICE LASE: .., <br /> APPLICATION FOR SANITATION PERMIT :> <br /> - -- -- ----------- ------------- Permit No..x <br /> (Complete in Triplicate), `` a 5 <br /> . 47 <br /> Date Issued � '---./ A <br /> Kf <br /> This-Perm it-Expires-1-Year From-Date Issued ,- ---- --- ----_- - --- °, <br /> Application is hereby made to.the San Joaquin Loco l`Hea'Ith-Oistrict 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 /> f JOB ADDRESS/LOCATION. - � 1�0------- --------- ojw ...A-41 ..---------------------------CENSUS TRACT.------ ..---- <br /> -�f� I .. � !� -.�` . '" r r/� Cit -.....-i4�,`--p�/ <br /> Owner''s-Name AY ` "/U. .C.. Yi/ �' Phone ----------------------- ------ <br /> Address...\�........ ........��..�...-- ee ----.......-; ..--------- :. y ------ --.... ----zip <br /> � . ...ticense #../�.--------�-- -- -- <br /> Installation wii serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> I <br /> �\ 6 Motel ❑ Other----" .......................- -------- -- <br /> Number of living unifs:;__- Number of bedrooms.,;t t ....Garbage Grinder.....--._..Lot Size...l �. )-eS <br /> Water Supply: Public System and name............ --------------- -- ------�- —= Private [,] <br /> _.-.. <br /> -•---- <br /> Character of soil to a depth of 3 feet: Sand R] Silt 0 Clay ❑ Peat ❑ Sandy Loam [❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.. •.... <br /> ....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 -------J <br /> Capacity../,;o-d Type.PX�_�/�T'7Matarial :No. Compartments------�A ---------------- ------� <br /> Distance to nearest: Well---.....-1404?--- --- --------Foundation----:t7- .. ......Prop. Line-. 0.�...... <br /> .. � s d f <br /> LEACHING LINE [ ] No. of Lines .'....- -----------.-....Length of each line-------P7�............. ..Total Length .. .-�-/ <br /> D' Box-.---Y.J.Type Filter Material.."A0!(; �__..Depth Filter Material--"-- . "---- - Q <br /> Distance to nearest: WeIIT.:.^,-._-.....--.--.: Foundation.---- .. pG� <br /> 1x60 ` y Property Line.....✓ <br /> SEEPAGE PIT ( j Depth.. ........Diameter--------------------Number---.--------------------••------ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth.--- ---------- --------- Rack Size-.. ........ <br /> . <br /> Distance to nearest: Well.-- ........ ......... ......... F n latioon.......� `...........Prop. Line----- -. ------ <br /> REPAIR/ADDITION {Prev. Sanitation Permit#----------------- Date.....--.:"....--: ----.-- -:---------.-....-) <br /> Septic Tank (Specify Requirements).---.. ------------------------------ ....... ----------- ---------------- ----- <br /> I 1 <br /> Disposal Field (Specify Requirements).- ----- •--- -------- <br /> ............................ ..... ......-- ........ .........------------------ -------------------------------------- _ " .......... ------ ----- <br /> ...........--- - ---- ---.......... <br /> 1 <br /> ...................... ------------------ ------------------ -------------- -- o'"� - <br /> ! JDrow existing and required addition on reverse side)I <br /> t �. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r Ordinances, State Laws, and Rules and Regulations of the San Joaquin_Loca11j'Health`DistFict,.Home owner or licensed agents <br /> signature certifies the following: 4 l <br /> "I certify that in the performdrice-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 Compe sation� laws of California." <br /> Signed <br /> ... 5y... - -------...Owner <br /> r1j --- ------------------ - <br /> s <br /> _ i <br /> ......Trie.� - .. <br /> (If-.o. r than owner[ ' <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-' DATE--------------- -------------- ------------------ DATE <br /> DIVISION OF LAND NUMBER --------- -- _------..;..-DATE.--- ...-- <br /> ADDITIONALCOMMENTS- ,..-..------ -_----- - ------ .............. ...........................�._----- ---------- .. ----- <br /> i - ------ --------------------------- - --------- ------...-----...---....._.... - ... <br /> -------------- -"-------- ......._ .... .....-..-.._....--.--.....--- . - ! <br /> } -------------------------- ....... . <br /> .---.. <br /> Final Ins etiron b :...... _.. ----.-- Date.-- 1. 1 r <br /> ---- <br /> ------------ <br /> y �� <br /> EH 13 24 SAN JO QUIN LOCAL HEALTH DISTRICTS 21677 REV. 7/76 <br />