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FOR OFFICE USE: FOR OFFICE USE: <br /> Y 'APPLICATION FOR SANITATION PERMIT <br /> ................ ............. <br /> (Complete in Triplicate) Permit No.71.7,""...__17... <br /> Date issued.& 42:2. <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: <br /> J08 ADDRESS/LOCATION----:�,S7dC1_...._p_---�I��....�a.4. -- -- c� /oc![��i, CENSUS TRACT.............. ...... ... <br /> - ---- <br /> C� ---- ------- <br /> Owner's Name. h_.>�f1.a ..t+Lf<=_....C�lJ. . +� .�U .q.�.e�!� --�-4..-v-------r------ ------------- Phone.--........... ------------ <br /> j 1 <br /> Address _. . . ------- -------- - - - ---------City----- ------------------ - Zip-- .._....... .----- <br /> Contractor's Name -- . Cc G. fi t-,___ . _ t.µ ..... .l f'' r'�^. ._.... �� <br /> _License # Phone.-�i! G...�9.......:........ <br /> �6 Ze-5:... <br /> Installation will se.rv� TResi e�'e ❑ Apartment House Com erc'al ❑ Trailer Court '❑.--� r <br /> Motel ❑ Other f ar.bQa^. <br /> Number of living units:........ _.Number of bedrooms-..--/-.. Garbage Gr^in�der...........1ot Size."......................... ......:............... . .. <br /> r Y ! N, <br /> Water Supply: Public'5ystem.and name.--... .: :_:..:------:-•-- ..-[/. . .r'G...�i(1. ��'-- --- --- ------- ---.... --------------- -- Private ❑ <br /> Character of soil to a�depth of. 3 feet:+ +Sanda❑� Silt ❑ Clay W Peat ❑ Sandy`Loarr ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe-E)- ., Fill Material . ._. ....If yes, tYpe�-..._.Z---------- <br /> ----------- t <br /> B, �. <br /> [Plot plan, showing size of lot, location'of•s,ystem in relation to wells, buildings' etc-must be placed on reverse side.] £� <br /> NEW INSTALLATION: (No septic't nk or seepage'pit permitted if pyblic,sewer isavailable within 200 feet,[ <br /> eL <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ( ]` µ. Size .'_fl.r'.'dd �4�-.. rf 4S <br /> ---------- Liquid Depth.--:-----.'---------- --- <br /> i . <br /> �� <br /> Capacity..,3 4 4. Type./�!_C'-CovS�_../�Mat�ia'I_c0 c� c'��... No. Compartments_ ' <br /> - [f <br /> ........ <br /> oundation..-_-... .O. .� _ .Pro Line..... 'QUO <br /> .� Distance to nearest: Well_.--------��Q.--=-.-- f - - - - - P• �'-------------- -� <br /> A.: r \1 • , <br /> LEACHING LINE J ] No. of Lines........----6--------------Lentg'th,of each,line.----...IQD--------.:.-_Total Length',' 1/1.00 .....6:10 <br /> DBOX.... ....T e Filter Material <br /> YP S ��c..1.'Q1bepth Filter Material-------------------. -- ------------------- --- --.--....--- <br /> ��� !. Property Line_ .....-•---- <br /> Distance to nearest: Well :4U....''-......Foundation...-._.._-.L. ........�. . � ..---•-- <br /> SEEPAGE PIT [ ] Depth.--.-...... Diameter--.-�--------------NUm,ber--------------E,� �!.-.¢•--.- � Rock Filled;I''Yes ❑ No ❑ <br /> nd1^ Water Table Depth.------------ ---------- --------------- --------.--.Rock`Size.................>-------------------` -------- <br /> Distance to nearest: Well ---- ', Foundation....... ................P.rop.f Line..... .... <br /> REPAIR/ADDITION {Prey. Sanitation Permit# - ---------------- -------- ------Date....--- .W -----..... -------: ] <br /> SepcTank (Specify Requirements).-..----- --------------------• - - <br /> � �.• `.. � j <br /> - ------ --------------------------- , <br /> Disposal Field (Specify Requirements)...................... <br /> ..............................-------------- <br /> t f <br /> .._.-. ....._. .......................................................................................................................................... <br /> ........................................................... -- - --------- - ------------- - -------- ---------- <br /> (Draw existing and required addition on reverse side`) <br /> I 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 Health District. Home owner or licensed agents <br /> signature certifies the following: Y' <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 /> to becom"b(ect to W rkm Co pens tion law f Cali rnia." <br /> Signe - ...... ....... Owner <br /> By_.........._--------- -------------- - ---------------------------------- Title ----------------------- ------ <br /> (If other than owner) <br /> FOR EPA"ENT U ONLY <br /> APPLICATION ACCEPTED BY...----... .. --------------------- -DATE ......L.I1-318.. <br /> DIVISION OF LAND NUMBER.-- ------ -- . DATE -- ,.. <br /> ADDITIONAL COMMENTS - -- --- --..----------------------------------------------------- --------- --------------------- .------... <br /> - - ---•------------ ------ .......... ....... -. ... -.--- ----- ---------- --------- • ................... -....................------------------------- ... . --.........- <br /> _...-.- <br /> Final lnspecfion by- Date...... .' �. . ... <br /> EH 13 2A SAN JOAQl11N LOCAL WEALTH DISTRICT F&S 21677 REV. 7176 3M <br />