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FOR OFFICE USE: r FOR OFFICE USE: <br /> " APPLICATION FOR-SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.......- <br /> -•-----•---•-------•---'------- ................. -�-- <br /> .............. --------- -'---- This Permit Expires 1 Year From Date Issued Date lssued_,S.-�-.�- <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.---:-7.e411- ._C-01C .5 �K. S7K/(� <br /> //,,,, -------------------- ------- ------ --- CENSUS TRACT.... `.........- <br /> Owner's Name..... .__.G{/. C.i!F_4" Phone a.��-IS-617.... ... <br /> --- - <br /> Address...--_.:411 , CO-�If )&. �j rZ/Z_ <br /> City..._.. .T��_...... Zip = ------ <br /> Contractor's Name.... �� 5 O�/S <br /> -------------- - ------...-.--- ._...--.-License #- `y_3. �...Phone_... �6 .%6 d <br /> Installation will s ve: 41rResidenceX Apartment House ❑` Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other........ <br /> Number of living units: ......I_----Number o _. <br /> f bedrooms._-._ _....Garbage Grinder--------.---Lot Size.__..-._ .- X � � <br /> I <br /> Water Supply: Public System and name.. ..PlleLl - Private F-1Character of soil to a depth of 3 feet: Sand ❑Silt ❑ Clay ❑ 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 reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permittedlif public sewer is available hin 200 feet ) <br /> PACKAGE TREATMENT { } SEPTIC TANK j } Size ... .1-- -------------------- ------ i epth.. .:---------...... <br /> ------ <br /> �X/ST/'v4 Capacity- -- - ---- - Type--- ---I ateri "---- - _�"No rrm'art ents •--------- oC . <br /> Distance to nearest: Wel ._. ---.. -- -- F ation. .... . __..?. .. .. Line...........................�C <br /> \1 <br /> LEACHING LINE { ] No. of Lines --- -- --- Le th ea '-h ............... . .......... T I'Leng h ... .................... <br /> --------------- <br /> 'D- <br /> ........--__-- <br /> 'D' Box- T e Filter teria - <br /> epth i at -- -1 ------ ----- ------------ --- ....-------� <br /> Distance,to nearest: ell =...... u dation,__-iF ��__--- Property Line----------- ----------............- <br /> SEEPAGE PIT <br /> E ] Depth.,-- -��-.....__Diameter. -----"- l�r 1be ---------------�-�1 - .. Rock Filled Yes ❑ No ' <br /> T/ . <br /> EKIS 71- 4* Table Depth.--------- ---------------Rock;Siie... .._ ... -- - ----- -------------------- <br /> - <br /> ------------------ t� <br /> Distance to nearest: �Fo-un�atrotl...... j - - Prop.`Line.. .... --.... ---- <br /> 4 y qq � <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-.---I3s . .......... ................Date-------------1. ...6.I------------- <br /> Septic <br /> ------. - .Septic Tank (Specify Requirements)'-----------............................... ....... ...... �3._-.._ ., - . __`._._...ti:-- E--�: <br /> �..f. <br /> ... - <br /> - <br /> Disposal Field (Specify Requirements) .44_46------ .. <br /> � . ------ <br /> .'_X.a / <br /> r 1 <br /> . i 11 /--N. <br /> -------- ---' --•- . <br /> - -. -- --- - ------------------- .-- .....---.---... <br /> Drw existing and required addition <br /> nreverse <br /> sine) <br /> I hereby certify that Ihave prepared thapapplication and that workwill accordance with San Joaquin ; <br /> 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 /> i <br /> to become subi. t to Workman's Compensation laws of California." <br /> Signed------. ----------- " Owner r <br /> By............. -'--- 2-Q Title.-- -- ---. <br /> (If other ES / I TO'� <br /> er than owner) <br /> F R DEP TMENT SE ONLY <br /> APPLICATION ACCEPTED BY------- ../L< ..... _.. ..--------- <br /> ..- �o'''^ - - --- ---------------------------..DATE ....... � - -�-.--��-- ..-- <br /> DIVISION OF LAND NUMBER......... -- ----" ------'---------------DATE---------------------------- - ---.-----..... <br /> - - -' " <br /> ADDITIONAL COMMENTS ----'---- ---- --..... . ............ ........ <br /> ------------------- . --...-----...... .............. <br /> ------------------------------ .............-- .. ------------------------ --------------- -------------------- ........' ------ ...... I <br /> --•------------- ................. ---•---•---------- -- ------- -----------------------------------------------------...._.------------- <br /> Final Inspection b ...Date_----- ------- r.. ----- .- ..... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />