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FOR USE: -• � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------- ---------------------------------------------- <br /> (Complete in Triplicate) Permit <br /> ----------------------- <br /> � Date Issued /__-/_.4�'7._ <br /> -------------____----__--------------------------------- This Permit ExpireAl Year-Front Date Issued <br /> Application is hereby made to the San Joaquin Local Health District foa permit to construct and install the work herein described. <br /> This application is made in compliance with County�Ordinance No. 54q and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION--------- ------�--� -� � ----- - - --- <br /> -� ------CENSUS TRACT------------------ - - -�• - <br /> Owner's Name---------------------------- ------13.e.,L-L ----------------- ------------Phone-_- A � <br /> r <br /> ._6_19'kos r---------------- ------- <br /> Address--- -------- ? <br /> Contractor's Name___________________ .__._-13, _"_rrfPrk0:�---------License #._ - � ----Phone_Of-7-fita-_.__. <br /> Installation will serve: Residence Apartment House.❑ Commercial F-1TrailerCourt ❑ <br /> Motel ❑ Other---=----------------------------------------- <br /> -Number of living units:___-__-------Number of bedrooms.---' Grinder---/-4Q__Lot Size_______ __----- <br /> Water Supply: Public System and name--------------------------- -------------------------------------------------- --------------------------- ---------------Private)o <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan K Adobe ❑ Fill Material__ --- ---- yes, type________________________________ <br /> (Plot plan, showing size of lot, location of system in 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, \ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth-------------------------- <br /> e)c% f Capacity --T e-------- Material--------------------------No. Compartments------------------/ <br /> t c~ _______ _____-_Foundatian ,3 ___. ____Prop. Lin __ SDistance to nearest: Well__-/_ �----- -------------- <br /> ------------------- <br /> ------ <br /> ---------------------- <br /> _ <br /> __ _ <br /> _______.__._ ___.___ _ � __LEACHING LINE No. of Lines-----------------------------Length of-66th'line_ --- __,_.__,__________ <br /> 'D' <br /> W <br /> Box------------Type Fitter Material._._._ __. Depth Filter Mate ' <br /> rzG Distancgtonearest: We.ll__1_._ ___ .Foundation�'l '_____ _____.Property Line----- _____________t_c_. u <br /> SEEP IT [ ] Depth._______. it._biameter_. -.__- lumber-------------------------------- Rock Filled Yes ❑ No <br /> S _ -. <br /> Water Table Depth ---�-------y--�-- Rock Size <br /> Distance td. nearest: Well..__„_!____________________________Foundation:-�"�D___ _.Prop, Line.-�___ <br /> REPAI ZXDpITION (f rev. Sanitation'-Permit#____.�_.'s __ ?"_________._ <br /> ``__ Date --- ----- -----------------------------------1 <br /> ' '� r' <br /> Septic Tank (Specify Requirements)_= ,,.�'__ __=-------- . __u _ <br /> Disposal Field (Specify Requirements). ` l_ ----- ��� --------- ----------------------------------------------------- <br /> -----------G I_X----Jo_X-------I- ------------ ' __________ _ __ i _�____A__�._________________________.__ ___._____._______.______________________._.____ <br /> . r <br /> (Dow existing and required addition n.reverse side[ <br /> I hereby certify that I have prepared thiJbpplication and°thTat tlse-'workli� ill[Ybe done..in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations 0th.e-San Joaquin Local HeclKDistrict, Home owner or licensed agents <br /> signature certifies the following: <br /> "1 certify that in tob performance of the work-for which this permit is issued,-'1 iliall'not employ any person in such manner as <br /> tiff - <br /> to become sub[e to orkman s mp nsation, I1aws'­of�Californi;a:,'� <br /> Signed --- --------- <br /> ' Own <br /> BY --------------- r , • Title <br /> ij <br /> (If other than owner) FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - t '__DATE. <br /> DIVISION OF LAND NUMBER __--- _ t' (- --DATE--------- -------------------------------- -- -- <br /> -------- <br /> ADDITIONAL COMMENTS--- --- -- ---- - ------------------------------- ------------ '---- <br /> _ w . -- ---- --------- <br /> - -_=------ "� ----------- ---------------------------------------------------- ' _ `.. <br /> --------------------------------------------------------------------------- - <br /> ----- "^ ------ ----------------------------------- '` ti `� - --------------------- <br /> --------------------------------------------- ---- -- - --- ----- - ----- - ------------ ------------------------------------------------------------- <br /> FinalalnsRection �y� . - --------------------- <br /> ---------------------- -- -- "W--- <br /> EH 13 24 SAN J AOUIIV-LOCAL HEALTH'DISTRICT F&S 21677 REV. 7/76 3M <br />