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FOR OFFICE USE: <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _ <br /> --------------------------------------------------------- Permit No._7?--- -- <br /> m (Complete,i n.Trl p l icc tp <br /> j v., c , x— .+ 4� <br /> - Date Issued--- '-3-_�� <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 comp a ce ith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --._.:. --------------------------------C f:._ c ------CENSUS TRACT..---- - ------- ---------- <br /> Owner's Name------ ------- �� '�.'V La ------- -------- ----------- - ------------Phone--------------.------------------- <br /> Address -- -------- ------ ��f `I cG : = ------------ --------------------------City-___ ------------ -------------------- -- ------------------- <br /> C"ty Zip-- <br /> 's Name = _ +)_ :�°� --: SQA'' --------------------- ----License #A—-- '�` '----Phone ------- <br /> Contractor ` <br /> Installation will serve: Residence [2f Apartment House 0 iCommercial ❑ Trailer Court ❑ \i <br /> ._ . Motel ❑- Other--------------------- ..' <br /> P-4 : <br /> Number of living"-units:______. __-___Number,.of,bedrooms----Y!----Garbage Grinder.-----------Lot.Size.r____ --j---YC.S-------------------- [� <br /> Water Supply: Public System and name --------- --=--------------------------- ----2'___.__.._.___----------- . ---- -- - ---Pri to [K <br /> Character of soil to a depth of 3 feet: ; 5and ❑^:Silt❑ Clay ❑•Peat❑ Sandy Loam ❑Clay Loam <br /> „� r "� <br /> Hardpan ❑ ' Adobe❑ Fil! Material__--- - ----If yes, type_-- :__-_-___ t <br /> (Plot plan, showing size of lot, location of system in relation to wells, build!ngs,'.etc. must be placed on reverse side.) <br /> NEW INSTALLATION: {No septic,tank`or seepage :pit permitted�:ifpu�lic=sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [f] SEPTIC TANK![ ] Size----------------------------------------------=-------------Liquid Depth--------------------------� <br /> Capacity_.e!0�'- Type �' _ .ry __Material__-_ �_______No.. Compartments- -______ __-____ <br /> 1 _ �G'f ,V r /�Q 6 <br /> - _ .. Distance to nearest: Well-:---�----A-----.,_--------------------Foundation------ - ---_>--------Prop. Line--- <br /> [ ] No. of Lines :------- - - Lt�oGeach line. '� - Total.QLength. �:- <br /> 'D' Box---- ---Type Filter Material----- _G1 __.Depth Filter Material____.___ _ __.__----------------------- i---- <br /> Dis#ante to nearest:-WeIL'-------Y---------------_-Foundation-----------------------------..Property Line------------------------------- --. <br /> SEEPAGE IT { ] Depth----/ �__Dir_1�-,------------Number-----= =-------- Rock Filled Yes No El <br /> r Water Table Depth----------.--- <br /> f -- ------=---------------------�-Rock Size`-�-�-----�--.�. -----------------------" <br /> 1!0 11" <br /> nearest: Well -----------------------Foundation- ---- .--,..Prop. Lin <br /> e------------ ----------- <br /> r r O <br /> REPAIR/ADDITION (Prev, Sanitation Permit'#----------------------------------------------- <br /> ----:Date----------------------------------------------1 <br /> Septic Tank (Specify Requirements)--------- ----- = ---------- --------- -�-'=---- -- ==� �-L"'—'----------------- - <br /> , ,, <br /> Disposal Field (Specify Requirements: = ----------------=---------------- ------ ---------..----:---------------------I- <br /> -------------�- r <br /> � GGAi--�P - - <br /> ------------ <br /> __ ------ -------- <br /> -i.e. � . �f. <br /> F <br /> (Draw existing and required addition on reverse side) <br /> I herby certify that 1 have prepared this applicationd that the work will be done.11n accordance with San Joaquin County <br /> Ordinances;"State'"Lawi, cind;Rulie's� and Regulations�of..the San Joaquin Local Health District. Home owner or-licensed agents <br /> signature certiifies the following: r i f E ? <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ d y person in such manner as <br /> to become subject to Workman's Compensation laws of Caifornia." <br /> ' <br /> Owner <br /> Signed f f ' ------ <br /> BY ' <br /> D <br /> -------------- Title; ------- --- <br /> - <br /> han"owner) 4 <br /> r- <br /> F <br /> FOR DEPARTMENT'USE-QNLY <br /> i APPLICATION ACCEPTED BY- E <br /> Z6— <br /> ------- -- - ------------ - - -----_-DAT 7..7 <br /> DIVISION OF LAND NUMBER --------- ---------------------------------------- <br /> ' �. ----------- <br /> ADDITIONAL <br /> =- ------------------ <br /> ----------------DP,TE.-- ---------- <br /> ADDITIONAL COMMENTS. - "------------- = -- ---------------------------------------------- <br /> l. �� ..-------- <br /> ---------------------------------------------- -------•------------- --- ------------------------- <br /> ------------=----------- ----------------_-------------------------'--------------------- - <br /> ------ - --- ------------------------------------------- --•--------------------------------- :---------------------------.-----------•--------------------------------- . <br /> F <br /> Final Inspection b "" ------------- <br /> p Y r"'� pate <br /> EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7176 3M <br />