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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit N <br /> ---- <br /> (Complete in Triplicat o..__ � � <br /> --------------------------- `7,;7/ <br /> Date Issued---- ----/-.Z---------- <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: M <br /> - -- -.. -- -�------------- � ------------------- CENSUS TRACT------------ <br /> JOB ADDRESS/LOCATION.... _.l.{Cl LS ------------t4 <br /> �// ------- <br /> /1! 6/H S ------Phone_.- <br /> Owner s Name.` . --------- <br /> - --- ------------------ <br /> /YI <br /> Address ------------- - -- - ---- ---- -----' A.........:--- -------- City - -G2-�;-----:----.2iP---q --------3-�'a--- <br /> Contractor's Name License #---- -- -- Phone< <br /> .- _.. totel <br /> Installation-will serve: ; ResidenceApartmentHouuse.❑]� Commercial ❑ Trailer Court ❑E] Other------------------------ ------- ------------= <br /> 1 ts <br /> Numbe'r of living units:.- _J ___---Number of bedrooms:..-___Garbage Grinder--_.-----_.--Lot Size_.__.'-�� -- ...............T -- <br /> Water Supply: Public System and name------- ----------` -_-----------------=------------------- .--------:-------- Private <br /> Character of soii'to a depth of 3 feet: San cI&A Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam) ❑ <br /> ..- .i- <br /> } Hardpan ❑ : Adobe Fill Material-........._If yes, type_.._-_- "_-_ ___._ <br /> r . � <br /> {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.must be placed on reve�r.se side.} <br /> NEW INSTALLATION: '(No septic tank or seepage pit permitted if public sewer is available w4n7206;eet,) <br /> - <br /> b 40k Liquid Dept._ <br /> PACKAGE TREATMENT . [ SEPTIC TANK "Size'-____.___.______.� --------- -- <br /> --=- ----:--- <br /> apac Y---= ---- ;TYPe- G '----Material - -No' Compartments------ ----�-------------------- <br /> o.�. t <br /> -. �� 1 <br /> Distance.to nearest: Well------------- i 5 -.-- Prop: Line_,:17-it-------�--- <br /> _ _Foundat.ion_..---- ------------T---- <br /> rr �..€�-. <br /> LEACHING LINE ]_ No. of Lines._____ Length o each line ._ �7 . Total'L"ength �-- <br /> 1 .{- <br /> Type Filter Material--.X"tg 13epth Filter Material.___-_ tel ' ---- ---- <br /> - r ri .---. _ _ <br /> { Di- nce to nearest Well ---Foundatioria�- Property Line.;---� �-� --------- - -i- - <br /> r. <br /> -_ .f� _Diameter_. j:( _Nvmber__� ____ - � y Rock Filled Yes No <br /> rS€€R,Atf�`PfT [ ] Depth.._ iY" x-1 <br /> �^^� WaYe Table.Depth.-------`�� ------- Rock.Size o�it- ---------------------- <br /> , r"'.. I <br /> Distance to he Well-------.; ---------------- Foundcfon. , _ Rrop, Line-____�.�_� _._.._ <br /> REPAIR/ADDITION (Prey:Sanitation Permit.# <br /> 71' !-" - -- �f----Date____3-L _ -- - 72.� { <br /> - 1 t <br /> Septic Tank (Specify Requirements):----------- ��. . . --��__ ----=----�- "'�����----------------s---------------------- <br /> --�----------- ---------- - =---. <br /> t ' <br /> Disposal Field (Specify Requirements)._____. <br /> } � ---------------- -------- ------- -------= <br /> - - ;: <br /> ---- - ---- _---- ------ <br /> -� --------------------------1._ <br /> ---------- - <br /> [ <br /> (Draw existing and required addition ontreverse side) � l <br /> ' <br /> I hereby certify that I have prepared'this;application and that'the :work will be done 4n accordance with i San; Joaquin County <br /> Ordinances, State Laws, [an'd-Rule_s- and-Regulations-of-theA'Snn-JoaquiwL!ocal Health District. Home owner or licensed agents <br /> signature certifies the following:,:, t <br /> "I certify that in the performance of the-'work for which-this permit is-issued,--.l shall not employ any,;p?rrsonYirr such manner as <br /> to become subject toaWorkman's Compensationjlaws tof Califo'r�nia.". <br /> .k.. <br /> Signed ; --- -- ---------------' Owner <br /> Y <br /> BY <"----� ez C¢-h'�? Title ----: <br /> j. _ (If other than owner) :'-�t ..�..:1 <br /> o- <br /> y FOR PEPARTMENT USE ONLY �. <br /> APPLICATION ACCEPTED BY -- ------ -- -- ------- -- : ' - --"DATE - -_- <br /> DIVISION OF LAND NUMBER,.__ - � .= ATE ---------------- <br /> ll J� <br /> ADDITIONAL COMMENTS 7 1. ------''---- "='--' '{ <br /> ...� <br /> --- <br /> .---------- ----------- --:---- --- <br /> �- a �✓�s E <br /> ----- ----- ----- ---- ----- --- - <br /> Final Inspection by__-_,_ _Q te. <br /> EH is 24 SAN JOAQUIN LOCAL'H ALTH DISTRICT Fes 2ia�� RE snn <br /> y j � <br />