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17y. :- <br /> FOR OFFICE USS' FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------- ------ - <br /> (Complete in Triplicate) Permit No. <br /> ------------------------------------ ---- ------------- <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District fora 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.... ._..... ... ------------ c:v-/ek AFP...... ------ ---------CENSUS TRACT................. <br /> 4` <br /> n --- <br /> Owner's Name ...� c. i ----- -------------------------------- ---- ----- Pho/ <br /> .� <br /> Address........ // 7 ....-- R ; <br /> �... <br /> Contractor's Name..... � �_r`1���. >........-------------- ------ ----.-....._.License #-p� -{S`��. .PhanerilLfJ-51V- ------ <br /> Installation willserve: Residence . Apartment House ❑ Commercial ❑ Trailer Court E]otel ❑ Other ......____------- <br /> Number of living units;.... ..--....__Number of bedrooms..3.....Garbage Grinder-----------.Lot Size.......111A..-�. ---- ------ <br /> ---------- <br /> Water Supply: Public System and name-- --- ----------------------------------------- ---- -- ---------------- Private <br /> Sand [D <br /> El <br /> Character of soil to a depthHardpaneet. Adobe S`Fill.Mat raal _ _: .y Ej Peat <br /> es, type Snd Loam"-----"--Cla L . <br /> ❑ ❑ Y <br /> i - <br /> Mot plan, showing size of lot, location of system in relation to wells,:buildings, etc. must be placed on reverse side.} n <br /> NEW INSTAL*ATION: (No septic tank or seepage pit permitted if public sewer is available within 240,feet,] cp <br /> y. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.-.,5 ....Liquid Depth..c'S --------- <br /> Capacity. --------TYpe6? .<457MateTial } No. Compartments.. - --------- <br /> J <br /> ...Pro Line.,- <br /> Distance to nearest: Well----� .-----__-.--•t- --•--Foundation_.-�a . __... p. -...."-- <br /> ----------Length of each line....- `T <br /> LEACHING LINE --. -.--- ---Total Length - Y . .�.._....-- <br /> [ ] Na, of Lines - __.---.. f <br /> 'D' Box----/......Type Filter Material-�,;'e �Depth Filter Material. ------------- -- v--- - ------- .A <br /> _.. ._ . Distance to nearest: Wel!" Foundation- t3 - .-Property Line-----J Q.... .'-- ------- <br /> SEEPAGE PIT [ ] Depth..... Diameter--------------------Number----------- ---------------- Rock Filled Yes ❑ No ❑` <br /> Water Table Depth--------------- -----------r . .�..?-".- /...`='Rock Size.-- ------------... <br /> Distance nearest: ------------------ <br /> #✓ .: - -....Foundation_.- Prop. Line <br /> REPAIR/ADDITION (Prev. Sanita#ion Pemit#--- ------------ ------ <br /> te. - 1 <br /> r Septic Tank (Specify Requirements)............... ----------------------------- ...... ------,--------- -- ................. <br /> Disposal Field (Specify Requirements)-"-_---- ---.-.. .. <br /> ­----------------------- ---------------- ---- ----•-- <br /> r r .---------- ------------- ...... ......... -------- -� ---------k , <br /> y� <br /> F _........ -- ----------- --------------- --- -------------------------- - ------ -- -------------------------------- � --- -: -;;.,.- ----------- ---- ------------ <br /> i (Draw existing and required addition on reverse side) j <br /> 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 Wealth District. Home owner or licensed agents <br /> signature certifles the following: ; <br /> "I certify that in the performance of the work'for which this permit is issued, I shall not employ any p)eron in such manner as <br /> to become subject W rkman's Compensation laws •of-California. <br /> . <br /> Signed---- a, ................... =-------------------- ----Owner• <br /> t ... ------- <br /> ..................Title...... --------------- ------------ �..---- <br /> (if other than owner) <br /> f <br /> PUFMAE T ISIS ONLY t <br /> APPLICATION ACCEPTED BY----- - --- ....DATE .-- {..:.fi .....-- <br /> ---------- - <br /> DIVISION`OF LAND NUMBER: '. .M.. .....r.....,. DATE._.-.....' - <br /> ADDITIONAL COMMENTS.............. ........... -- ---- -------v- ------------•--- . ------------------------------ ---- <br /> 1, " <br /> ------------_--•------------------ ------------- ----------------------- <br /> b <br /> f � .... ....... . <br /> i ------- ------------- <br /> ----__.-Date.Fina! Inspection by:.... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ^P&5 21477 REV, 7/76 3M <br /> ` <br /> s <br />