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ry FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.7 g`_a�-5--- <br /> ----------------------------------------------- --------- (Complete in Triplicate) -V .2 1 <br /> - Date lssued,5-J_� 9 <br /> ---------- --------- - <br /> ----- ------------- <br /> This Permit Expires"1 Year4rom Date-Issued 1- l <br /> - � 4 <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 County Ordinance No. 549 and existing Rules and Regulations- <br /> `76 <br /> egulatin <br /> JOB ADDRESS/!OC TION _ , f k tlI <br /> - -- - <br /> CENSUS TRACT. <br /> --- - --- <br /> Owner's Name .._._ _ ---Ff� M- = .:. hon -. , <br /> -- - ---- ---- <br /> �/�• _z i T <br /> .__. --_.._ - -.__--------------------- <br /> Ar <br /> _ ____ ______ ___ _. i-- h <br /> 2� A - U _.--=--- ---= -- .City <br /> Address- .� <br /> CR�IIe ' -- ------- - <br /> Contractor's Na"me __._---- M - <br /> Y3 �/8 F Phone d Gam `-/ <br /> -" ' License # �� <br /> will serve: i Residence [�- Apartment House.[ Commercial ❑ aTrailer Court; ❑ { <br /> Installation ; <br /> j. y.. Mate] ❑ Other------- ------- =' ;. <br /> Number of living units:-_� <br /> �, -=------ --- ---- <br /> Number of bedrooms .3:."--Garbage_Grindex._.�_�oi Size�i--��-- --------------"--------- <br /> g j 1 i <br /> 1 ." Private <br /> s � ; <br /> Water Supply: Public System and name-:; .: -- _--=----=----- =- ------------------------- <br /> la_ <br /> Character of soil to a depth of 3 feet: Sand ;Silt 'Clay Peat Sand)barn y Lodm ❑ y <br /> ® ❑ Y ❑ ❑ Y ❑_. 4 . <br /> Hard an Adobe ❑ Fill Mater+aL.._�..____If yes, type____._ <br /> (Plot plan, showing size of,lot, location of system in relation to wells�buildings,.etc. must be placed on reverse side.) a <br /> NEW INSTALLATION: (No septic tank or' seepage pit.bermitted +f ublic sewer is available within 200 feet,) s <br /> 4 <br /> tSize_ L th."k X �� Liquid Dep <br /> i <br /> PACKAGE TREATMENT' I ] SEPTIC TANK [`] P, W � <br /> ff ���J ,..+T �.fi� Materi6l:___C +.No. Compartments--=----�--- -------------€ <br /> Capacity-- ----- -- - - YP. -- <br /> t i /O `. Line------ -- - -- <br /> f Distdnce.to nearest: Well.:. __ /' � -- .-�'-- -------Foundation- ___ __ Prop. <br /> + ., ? i 2 -c)------- ------------ <br /> LEACHING LINE - [j <br /> Na. of Lins <br /> -' -------- Filter Ma eeag ����- -IkDepth Filter Mater' ' <br /> - - - - ial.Tota �n th �-------,----- --------- ---------- -- <br /> D Box - -Type <br /> OW Foundation__. ------------------------------- <br /> --------------- ---Property Line <br /> 'Di's'tances to nearest. Well -! -.------ <br /> - k Filled Yes ❑ No ❑ <br /> SEEPAGE PIT I l P� D ;__--Number ---------------------------- <br /> meter-: R k <br /> De th <br /> Roc <br /> Water Table;Depth.--;----------- ----Rock Size = k <br /> '"t r "� .J �. Foundation".` = -'---------.Prop. Line---------------------, - <br /> Distarice-to ned res`t"•Well.' ------------------------- <br /> ------- <br /> --------=---- --- <br /> j ( = Date ------- ---=------ ----- ------------ <br /> REPAIR ) <br /> a, /ADDITION (Prev:Sanitation Perml.t'#-------------------------- --- <br /> p (Specify q -------- ------------ -------------- <br /> --------= - -------- -- ----------------- <br /> I �Ir 4 vy! �-'- = = <br /> Se Itic Tank'(S eclf Re uir�ment }_ y 6:------ = <br /> -- ----- ---------------- =----- ------------- ------------------------------- <br /> Disposal <br /> Field.(Specify Requirements}-....___._.}_.. - ; <br /> �- I : . _ ---------------------------------------------------------. - - - <br /> ----------- ------------- - <br /> : ; _ <br /> ( <br /> .,. <br /> ------------------------------- <br /> '- - <br /> --- ----------- <br /> - <br /> Draw existng and required'addition,on reverse side) <br /> I hereby certify that l have prepared this application-and that the work' will be done in accordance with San Joaquin County <br /> Ordinances, State I:aws, and o12ules`.and Reguiations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> { { <br /> "I certify that in the performance of,the v✓ork'for-which this permit is issued, t shall not employ any person in such mannerfas <br /> to become subject to Workman's Comp sation..laws.of California.". <br /> 41 <br /> Signed ---- <br /> �/►tiy - ----- n . . ... <br /> 1 Title------------ ------- --------- <br /> { (If other than weer) <br /> FOR EPART ENT USE ONLY <br /> ss^-�-K -; ---DATE---- ---. - ---- -------- ----- - --- ----- <br /> ---DATE --- -- ----- ------------- <br /> -- '------------ <br /> APPLICATION ACCEPTED BY----------- --------------- - ------------------=------ <br /> - - -- ----- <br /> DIVISION OF LAND NUMBER --------- --------- --------------- - ----- -----------:--- <br /> ------- --� - <br /> ADDITIONAL COMMENTS ------------------- ------------------------------------ ------------ <br /> ------ - <br /> ------------------------- <br /> -------------------------------- <br /> ------ ---------------------- - -------- ---------- ----------- • ----------- <br /> 1 ' ------------- -- '-------- ---- <br /> t _ [: _ -----T <br /> G� ---------------- -------- ----- - <br /> r - - --- <br /> i Final Inspection by: � T -- ------ ---------- -------------Date--- =�� -f/`' ----.--- ---------- --- <br /> P -------------- --- "- - - - F&5 21677 REV, 7/76 3M <br /> f.H 1734 ti SAN JOAQUIN LOCAL HEALTH DISTRICT -mow <br />