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F <br /> FOR OFFICE USE: OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 3 <br /> ----------- -- 9 9`_5 <br /> �i (Complete in Triplicate] Permit No.................. ...vZ <br /> S" <br /> 1Q ------------------------------ <br /> ----, --- Date Issued--- <br /> .................... ----------------------- <br /> ssued................................................. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin-Local Health D,istr-ict_,for a-permit to construct and install the work herein described. <br /> This application is made in compliance with Ceurify Ordinarice'No'. 549 and existingf Au_and Regulations: <br /> JOB ADDRESS/LOCATION....409t1.... --------- CENSUS TRACT- ---------------- ...... . <br /> Owner's Name ........PA.h1.... *.Prli'PT¢' ...............: . --Phone. ------- <br /> Address.... <br /> ---- <br /> Address....- P� .. �X. 1r.B-� . ....... ---- ... .. City_ AU94P 1A"e- .--.- - - ..ZIP 'a��s8 <br /> Contractor's Name.---P-j.Q- .4AeISIy_..%_4�0—T...----.-.- ...........License # 5 3..... Phone ``9A4P ....-. <br /> Installation will serve: Residence R� Apartment House ❑ 'Commercial 0 Trailer;Court ❑ <br /> Motel ❑ Other-_AloAA&E- <br /> Y <br /> Number of living units:.............Number of bedrooms.---oZ....Garbage-Grinder-- -�- Lot-Size. . .."�� ... . .-"" .- <br /> Water Supply: Public System and name:...... ... . "`` <br /> Private R <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ® Clay,Loam_[] <br /> - <br /> Hardpan.,M- , Adobe ❑, Fill Material.. .... ._ If yes, type-;-------------------� <br /> (Plot plan, showing size of lot, location of systemtin 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,) O <br /> y <br /> PACKAGE <br /> • TREATMENT SEPTIC TANK -Size .................•-----.------ ...-----.--', Liquid,t be­ ..'.---- ------' <br /> - <br /> C ; <br /> :__.- <br /> CapacitY-- - -- - ---TYPe------------ --.---0--. -------------"..No. Compartmenfis-----.....--- ---- ....... <br /> I ' „f. <br /> Distance to nearest: Well_---------------- ....Foundation--------- - --- .....Prop. Line..--. __.....----- -- _ <br /> LEACHING LINE [ ] No. of Lines - --- --_---._.---_----.Length of each-Fine.-----------------------_Total Length <br /> D' Box.-'- _.T t <br /> . -Type Filter Material. . Depth Filter Material--- .-,--...----.....---...----..----.....-.... <br /> Distance to nearest: Well..................... Foundation.._........k."--".........-Property Line...----------- .----i...-. . <br /> t 'f : ----- Rock Filled Yes No <br /> SEEPAGE PIT { ]; Depth .---..-- --`_-Diameter-.------_--- -.---Number-----"=---=--------------- ❑ ❑ <br /> t.� Water Table Depth-------_.......... ... ,---------------- Rock Size..........----- - ----------------.:.---•--. --- <br /> •`=' 6 <br /> Distance to nearest: Well--.---_=--:--,:.G_--:-.- -=- --- - <br /> •--Foundation-----------{..... .........Prop. Line....---.---........--.----- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#. `_-7!...... ' r ---- --- :_..Date` ---••------_- - ------- ------------- <br /> A <br /> -------- -- ] <br /> Septic Tank (Specify Requirements)_...... -------------------- -------•----"•---- ------- ------------- ..... ............... .......... <br /> Disposal Field [Specify Requirements)--- <br /> _ 15 <br /> N <br /> --------------------- ---------------!-------i-------- ......... ... . .................-.......... -- .---.--. <br /> .. .g�, h work will b clone in ac..._._..... - <br /> - i <br /> - - <br /> (Draw existin and required addition on reverse side) f <br /> I hereby certify that I .have prepared this application and that the o e jcordance 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 /> . s• I <br /> signature certifies the following.-' �} <br /> "I certify that in the performance'ofjthe work for which this permit is -issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." r <br /> SignedP. ...--. Owner �: <br /> (If other than owner) <br /> a � i <br /> FOR DEPARTMENT USE ONLY € <br /> APPLICATION ACCEPTED 13Y -- DATE ...-- --q-1�..............._`:....... <br /> DIVISION OF LAND NUMBER - --DATE -----:-- { <br /> ADDITIONAL COMMENTS----------------- ' --- ---- . ....---- <br /> ------.._..... ....................... .......:.....................------------------------------------------------- <br /> Final Inspection b Date .. _�.���� - . .. -*.----- <br /> y:... _ .. ------------------------------ -------•--•. ---- ---.... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F6S 21677 REV. 7/76 aM <br />