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`i FOR OFFICE <br /> OR OFFICE USE: <br /> T APPLICATION FOR SANITATION PERMIT <br /> Permit No... <br /> f --------------------- --------------------------- 7-__�_ <br /> (Complete in Triplicate) <br /> ----------------------------------- ------------ ------- <br /> -Date Issue_ d__'...--)--_.___ <br /> ------------_----------_----- ----------------------- This Permit Expires 1 Year From Date Issued R <br /> 0 3 - •6!110--13 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andinstall. the work herein described. <br /> This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> 5 e c©E'er'_v <br /> � flQf � -C ----- -C-�- <br /> ----------- <br /> JOB ADDRESS/LOCATION. _ _ ENSUS TRACT . <br /> Owner's Name.------- ----- <br /> Phone------ --------------__�?: = Q /- <br /> ------------ <br /> Address - -------------- t� � �.. -----=-------City �,Ca�;..:. ziP: <br /> Contractor's Name_.__,/ �-----Cl".4) --------------License #--,3Z;0 <br /> L ' _Phone - <br /> Installation will serve: Residence ❑ Apartment House. Commercial ❑ Trailer Court ❑ i <br /> t Motel ; Other.. / : <br /> Number of.living units:__:----____Number of bedroorrms_-__.._Garbage Grinder-��__Lot..Size_./ C` 2i ____________________ _______ <br /> Water Supply: Public System and narrie - :: - -------------- -----=------- ----- Private <br /> Character of soil to a depth of 3 feet: Sandi Silt. Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> J a: ..Jf es, type-_ - <br /> Hardpan ❑ Adobe ❑ '-„FiII Materia,!__.._.__ y e_._,__._________ .. { <br /> (Plot plan, showing size of lot, location of system in relation fayvells, 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 fee!L p <br /> PACKAGE TREATMENT"[ -]" t-SEPTIC TANK ] ] '. Size :` L�iG_4 -L:- / _--'`Liquid Depfih l3------ <br /> .__ E - <br /> Capacity i _L�� _Material yz '�� No. Compartments__ <br /> �3 ___ �__ <br /> Distance to nearest: Well 6,_,_________________ _____--Foundation:_;__11;74P_--____.'._Prop. Line---- ._ <br /> LEACHING LINE (,] No.. of Lines_',__- _________________Iength,of each line._._ '�'�--_:-_ __.__.Tota! eength �z�-'�'__.__._______�,_;�. <br /> yy ' <br /> Box.�_._:__Type Filter MateriaLElzu1Depth Filter Ma#eria! _ _ <br /> Al' <br /> ------------------------------- <br /> D' / . <br /> • =TC� -. <br /> F = = --- e <br /> ( ] De:Distance to Weare a et lr._� _.Number Foundation-._ . �--�`-- Pro ert Rock <br /> p �(/l} d Filled YesNo <br /> Water Table Depth ----------- ----- --i- -- <br /> i stance to nearest:'Wel1___ C '____ �--__ �ou., at3o ._ �U__ _e •ti .PropLine _._._ { <br /> , •REPAIR/AD'bM40N_Frev4F Santitation Permit#---------------------------------------------------- Date-------------------- <br /> ----------�- ----- - - --- -=---] ' <br /> I -�- i I l ns ` � c t --------- <br /> Sufic Tank_(Specify,�Requirerne�tsl---�---�.-. --,.-- - -------=------ ---- ---=------------- --�----- -- --------- - - <br /> _ �r <br /> Disposal FieldSpecify quire ents] .--- ----- -------- 1 #D <br /> -----y-----"---'- -' ------ -- ------ -"""------ .r- --------- -------------------------- . -----:---------------------------------------. ------ya.•- <br /> t - _ ------ <br /> = ' ---------------------------- ----- <br /> j * (Qr w existing and required addition on reverse side) `gyp <br /> I hereby certif*!hart-.have prepared -this.;application and that the work will be done—iit accordance withd3cn Joaquin County <br /> f Ordinances,' State Laws; and Rules and Regulations of the' San Joaquin Local Health Dis_intf,'Home owner oir-1 icensed agents <br /> signature certifies the following: sem, <br /> ..I certify,that in the performance of ahe work for which this permit is issued, 1 shall not employ any person'in such mdisner as <br /> to become. subject. to.Workman's Compensation:.laws of California."' , <br /> Signed = = --- --------------- <br /> ------ <br /> ---------- ,: caner <br /> t BY-#------' w A <br /> -.--=- L ----:.Title <br /> T <br /> t � <br /> i r---� (lT"ofher than_owner] <br /> R DEPARTMENT USE ONLY-i,I ams t 1 <br /> �.. ,.�__'_^°� . - --DATE__ _ . <br /> APPLICATION-4-A -EPTED;''aY' ---- � <br /> DIVISION OF LAND NUMBER:--- 77-fz- DATE-- <br /> ADDITIONAL COMM.ENTS- --�5�/Pla.1�a4'IL--C,C. - ------------------------ -------------------------------- � ---------------------------- -. <br /> f <br /> E _______________________________ —__.-__ ..___.__-__ <br /> ..____________ ___.._..._________.______.___ __ <br /> ______________ __ ----- <br /> ----------- <br /> _---------------. -------------_---------.------------------------------------------_----------- --------------- <br /> ----------------- <br /> Final Inspection-by--------------- <br /> R _ <br /> `�eH 13 2a SAN.JOAQUIN LOCAL_HEALTH DISTRICT __ p&s 21677 REV. 7/76 3m <br />