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FOR OFFICE USE: , 1111/ fL AOR USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - „ (Complete in Triplicate) Permit No. <br /> ----------------- <br /> Date Issued-/-. _'K_ . <br /> •--•--------------- ----------- -----------------.-A This Permit Expires 1 Year From Date Issued <br /> Application is hereby made-to-the Sa n-Joaquin Local Health District for a permit.to construct and install the work herein described. <br /> This application is made compliance with County Ordinance No. 549 and existing Rules and Regulations: " <br /> JOB ADDRESS/LOCATION.--- <br /> -.--.-.CENSUS TRACT <br /> �2r� ---- ---- D_ a <br /> Owner's Name.'.. q .�/ � - --.-�•.� ------------ <br />-Add <br /> --At---- . <br />-•---Address.��, _ _ Crty-� <br /> -�4-+ . _- <br /> Contractor's Name _0..ww_�_ rQ-"'__-�.]► L(r"-.--- =Lac se�# _E P1�one <br /> ` �� ---- ------ <br /> Installation will serve: Residenct?-ow pprtment House ❑'Com'mercial ❑. Trailer Court ❑ <br /> E Motel}'❑ Other----- --- <br /> t / , <br /> Number of living units:-.-s-----_----Number.of`,bedrooms.:___ ,____Garbage Grinder._ __._-_---Lot Size__.._ .7_,i -____t_ <br /> g } <br /> Water 5u I Public 5 seem and name E .* t . 4 .. _' :_-_' 4 �❑ k <br /> PP y ' yp- o . f £.. ❑ w� 0 P ❑ -:Sandy <br /> o m y L ❑ Private i <br /> Character of soil to a d'e th of 3'feet Sad Silt Cla Peat Sand Loam Clay <br /> Loam <br /> -�--�-- Hardpan-0 Adobe t❑,. Fill-MateKaI I If yes, type --------=- _-----= i <br /> ;< <br /> JF 7.�-- , a <br /> (Plot plan, showing size of-'lot;location of`sysfem;jn r�elation to'wells, buildings,'etc.must be placed on reverse side.) <br /> NEW INSTALLATION- 2'.(No septic tank orlseepagelpit permitted if public sewer is vailable within 200 feet) " ---' <br /> PACKAGE TREATMENT ['] ' SEPTIC TANK ;;. Size Z�t� ..�e.,. '- " --Liquid Depth,---- ---_:--- _� <br /> Capacity.t:�Q- ; e-— ---------� -- - aerial-+ ,n/C,. _No, Com artments------ <br /> ----------- <br /> or D[+ <br /> # .ii P --------- p <br /> t �„ / - �� <br /> Distance to Weare • Welia� ,.',- ._ .Foundation; 1Q•_ ._ ...Prop. Lin}_ _ __ <br /> LEACHING LINE,• No. of Lines___. .,_'t► ` __ . Length;of_each Ii _,._� rotaJl Length ........... <br /> .___. ��_p <br /> t 'y <br /> 0 D' Box._._ __ Type Filter Material I_ �� <br /> alter N�aterial _.�!r�________. __---- l <br /> �r, `' `x�r, ,cPp-8y <br /> s o nearest. Wel'L.��� _ r _ Foundation _ _._ _. . ._ .. ra ert Line.-:7; <br /> i J !- �. : _ <br /> SEEPAGE PIT [ ] Depfh____------------Diameter-. _---Number---- _ Rock Filledr'Yes ❑ No <br /> ' Water Table Depth----------------r--------------------------------°.----Rock Size-------=----------- . - € l <br /> Distance to nearest:Well-=---------------------------- ------ ---- Foundation--------.-.------------ Prop. Line-------------------- <br /> REPAIR/ADDITION-(Prev, <br /> --------------- <br /> REPAIR/ADDITION lPrev. Sanitation Permit#--------- ---------------- <br /> ------ :_Date-----------::--------------------------- ------ <br /> ) E <br /> Septic Tank (Specify Requirements)------------------------------------------------------= -- = / - • '� k---------- <br /> Disposal <br /> = r a <br /> i e <br /> Disposal Field.{Specify Re quirements)_.___.__ ,.�_ _-_-.� b "Z ? <br /> s + - -------------- ----------- <br /> ------------ <br /> ---------------------------------------- ' __ - - 8 ' <br /> -- -- -- - ------------------------ -------- ------------ - <br /> ----- =------------------------------------------------------------------ <br /> - - <br /> (Draw existing and required addition on reverse side) ' T <br /> I hereby certify that I -have-prepared this application and that the work will be done--inaccordance 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 /> signature certifies the following: <br /> f <br /> "I certify that in the performance of the work for which this permit is.issued, .I shall not employ any person such manner as <br /> to become subject to rkman' Comp nsation laws of Calif* <br /> Signed.- ------------------- <br /> By <br /> ' <br /> By---- ------------------------------------------------------ -- Title <br /> -(If other than owner) <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- -- ---- - - -----------=------------------------------DATE.:--- --7i'?,� <br /> DIVISION OF LAND NUMBER-- ------------------------------ --------- - DATE ' <br /> ADDITIONALCOMMENTS - --------- ------------------------=------------------- -------------------------------------- ----- ------------ <br /> ------------------------------------------------- ----------------- <br /> ------------ ---------------------- -- -- - ---- - ------ --- --- --- ----------------------------- -=------ ------------------------------------- -------------- <br /> -------- <br /> Inspection b ,/� <br /> P y:.(! - . ------ ---- ------ ---=------------- -------------- ----- Date <br /> EH t3 24 ��--���---- _-._.�------ <br /> SA JOAQUIN LOCAL HEALTH DISTRICT F&7t7P. 7176 3M <br />