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FOR OFFICE USE: * ' <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> - -------------------- -- <br /> (Complete in Triplicate) 2 � S <br /> Permit No. <br /> This Permit Expires 1-Year-Erpm-Date.Iss-ued Date Issued_ _._7-- 17 <br /> Application is hereby made to the San Joaquin Lo4LHealth 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.---- _ ..'�. C ------CENSUS TRACT--------__-- <br /> k <br /> Owner's Name=------- -------- Phone- ` <br /> 71 <br /> Address-- � .` ' ------ -- -----------* . ..., ��� ' <br /> Cityl�.....'__�st��'�---------z <br /> Contractor's NameiA " _ _ �, I 1c s#, ` : hon <br /> 1P -- <br /> _ <br /> --License <br /> Installation.will serve: Residence ; Apartment House ❑ Commercial ❑ Trailer Court E] <br /> er----------,- <br /> Number of living units:-._.:..r' I � � ' <br /> Number of bedrooms <br /> ci #_..Garbage Grinder.-.- --...Lot Size .-_-- '---_, -- . <br /> Water'Supply: Public System T = <br /> ------- ---------------- ---------- ---- -- Private <br /> Character of soil to a depth of 3 feet: Sand n:--Silt 0 !Clay E] ' Peat[j Sandy Loam ClayLoam <br /> Hardpan ❑ Adobe E] Fill Material..-__-------If yes, type---;-----------------'_ <br /> - -------- <br /> (Plot <br /> ------(Plot plan, showing size of lot, location of system in. relation-to we4s'buiIcings,-atc. must be placed or e e.rseside.) ; <br /> NEW INSTALLATION: (No.,. septic tank 'or seepage pit permitted if public sewer-i§ available within.200 feet) o <br /> PACKAGE TREAT FENT [ ] SEPTIC T i -� <br /> ANK - 1. . <br /> F � � -----------------TYPe ----------Size..Material--�-------�'---- <br /> ------------------ <br /> - L1qu1d Depth-------------------------- <br /> *• Capacity.,,: -`� w. <br /> _No. Compartments-------=---- - ---------- ---- <br /> Distance to nearest: Well -------- -•---Founddtion-------- ---•-'-----------Prop. Line--------------------------- <br /> LEACHING LINE (I ] No. of Lines,- ..................Len th of each line---------_a._3 � ": + i <br /> s .gTotal Length <br /> �y /. {� <br /> ( °-'% 'D' Box -.Type Filter Material_,.-. ..-___-.._Depth-Filter Material �-_ � -- I -- <br /> .. . . ._ I;; --. -------- ---------- ------ <br /> Distance to nearest: WeIL_____________---------------Fou V. _-.Propert Line_--,....____ 9 <br /> SEEPAGE PIT [ ] Depth-- --------------Diameter-------- <br /> -----Number }! <br /> Rock Filled Yes ❑ No ❑ <br /> ( Water Table Depth----------=--------------------------- - Rock Sized E' l <br /> 1 h =--------------=------- ----------- } <br /> REPAIR AD <br /> �vDistdnce:to <br /> nearest: Weil-: -------------- ---------- °.Foundation--- --- -- --------- Prop. Line---------------------- <br /> / DITION [Pr . Sanitation Permit#..` ------------ <br /> -----------------------= \Date------------ 3 <br /> pt -d <br /> ------------ <br /> Septic Tank (SpecifyRe irements)... _ . ! <br /> Disposal Field (Specify Re <br /> nv3 uirem nts�tI . r. <br /> r �� <br /> r __ -`� I <br /> ---------------------------- Ff <br /> -------------------------------- -- <br /> -------------- <br /> =------------------- - <br /> - --. <br /> -- -- <br /> (Draw existing and required addition on reversee sidee) <br /> I hereby certify that I have-prepared this application and that the work will be done in,accardance with San Joaquin County <br /> Ordinances, State Laws; and Rules and Regulations of the San Joaquin Local Health Dons Home owner or licensed agents I <br /> signature certifies the following: ]' ;• i <br /> >-3 t <br /> "I certify that in the performance of'the work for which this permit is'issued, .shall not:employ any;pe son in such mdnner as <br /> to become_ subject-toWorkman's. Compensation .laws of California." # <br /> Signed.-.- <br /> B --------------- <br /> Y --- ---- l , , .. ! E „� Tifile_. <br /> ' ------------------------ <br /> FOR. <br /> ----- -- -"------ { <br /> [If other--than ow r} � � i � - <br /> FOR.DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-__ P <br /> - --- --- - ----- DATE+��7- `Z 7 <br /> DIVISION OF LAND NUMBER-------------------_-_-- ---- --------_;--- <br /> ADDITIONAL COMMENTS-; DATE ' <br /> a�fspG�1tP�c._l��o, _ J x.� ,4,C"-- c¢a� --------- <br /> -�------ <br /> ---------------------- ---- <br /> --------------------------------------- <br /> -------- ---- ---------------- <br /> --------------------- - -------------- -- ------ ------------ ----------------------- <br /> Final Inspection by.-- =---------=---- = `` �... <br /> ; . <br /> Date 7 - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT';` -- F&S 21677 REV. 7/76 3M <br />