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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT pp <br /> ----------------------- Permit No._7.f-n1�o_ <br /> ------------------ <br /> (Complete in Triplicate) <br /> Date Issued--a--.L7--79 <br /> P' - <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 Country Ordinance No. 349 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION--fi- ------ ---G v---'1/ I� _...CENSUS TRACT------------ -------- <br /> _ _ <br /> Owner's Name.-. . . � lee_-e--v47e45 <br /> --------------------- - --- -------- PhonA91:2 <br /> Address------ `�� 0------- W------5.,45L� -_ )-------------------- --------Zi <br /> Contractor'slNa_•m_ey.". . 1 --!"CAC Z,-1F --------------------License #v ,� ---Phone.-1. --- <br /> Installation�wil serf Fve� `6-+ Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> \ Motel ❑ Other----- ---- ---------------------------------- <br /> Number <br /> ---- - ---------.Number of living units.____°:.--____Number of bedrooms.-__�-----Garbage Grinder------------Lot --------- . - <br /> / rte- 1 <br /> Water Supply: Public System andC- <br /> �name---- A-4-------- ( --------------------- ---------------------------- Private 11w, <br /> Character of soil to a depth of 3 feet: \Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ C4ay Loam M <br /> Hardpan Adobe ❑ Fill Material......------If yes, type----------------------------- <br /> (Plot <br /> _______.:.................(Plot plan, showing size of lot, location of:system in relation to wells, buildings,etc. must be placed on reverse side.) Q <br /> N. <br /> NEW INSTALLATION: (No septic tank or�eepage pit permitted if public sewer is available within 200 feet,[ �1 <br /> ',% g or <br /> PACKAGE TREATMENT [ ] SEPTIC-TANK [ ] Size_..-6--- L .�___________________Liquid Depth__-..-------...._ <br /> Ca alit = ''�"`-t-.-_T e _ - ' __Material------_ ----------------- <br /> p y, - yP � No. Compartments <br /> 1_^---- <br /> i <br /> Distance to.nearest: Well----------- L_Foundation.__ ..-----_ _-___Prop. Line_ -. - <br /> - ,& � �4 o- <br /> LEACHING LINE] [ ] No. of Lines-.--I-.---------- of 4- 4 line- -----------------.Total Length ----------I4Q C <br /> I 'D' Box_/--------Type Filter Material_-1/ /4Depth Filter Material._... ............................................... <br /> [ Distance to nearest: Well-------- _.-------- <br /> __------Foundation-.---------------------------Property Line--------------------------------- <br /> SEEPAGE <br /> __ .-..-----.---------SEEPAGE PIT [ ] Depth./T-_..___DiameterT__Y.4C`--- Number_.__'.,L_;='___---------------- Rock Filled Yes No E] <br /> € Water Table Depth-------------- -------- ` -----_---- ----- _.Rock Size------------------------------------------------ <br /> `ki Distance to nearest: Well ---- ....-------Foundation--------------------------Prop, Line.._..-----..---_-----...-_ <br /> REPAIR/ADDITION (Prev, Sanitation Permit#--------------------------------------- ----------Date\ _____._--------------------------.) <br /> Septic Tank,(Specify I�equiremerats)---_----_-----------__­- -------------------------- <br /> Disposal Field (Specify Requirements)----------------------- - <br /> = ----- -------------------------------------------------------------------- ------------------� <br /> = f---- _,L------- -------------------------------------------------------------- <br /> f <br /> (Draw existing and required addition on reverse side)- <br /> I hereby certify that 1. 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 /> i <br /> signature certifies the.following: S '. <br /> l 1 <br /> "I certify that in the�p rFormance of the work for which this permit is issued, I shall not erQ10y any person in such manner as <br /> to become subject ] s oenscitioni, laws of California." ` <br /> Signed .y��.��k��C - + Owner `s <br /> - <br /> BY---------------=-- - - -I - Title-------- ------------------------------ - --.='t --------- <br /> (If other.,than. owner) / <br /> ] FQR, EPXR ENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- -- -- ^`""--- ---- ----- -------------- *------------------- --DATE ; l`� -7? -- <br /> DIVISION OF LAND NUMBER..----------------- ------ --- -- --- i DATE . <br /> -- <br /> ADDITIONAL CO-M-WENTS---------- <br /> ------ ------"Tb <br /> ----- <br /> ° --- � <br /> = -� - - ----- ------Final Inspection ~' ! <br /> ------ ------ ------------------------------------------- -------------- - --------------Date.----- -- --------�. <br /> tH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 R <br />