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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------ <br /> (Complete in Triplicate) <br /> Permit <br /> --- <br /> Dote issued_ <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> /eta �1 <br /> JOB ADDRESS/LOCATION- _-- __-- --�Z- ----_ `_- -T�------ ----- ---- CENSUS TRACT _----- -- <br /> Owner's Name-----G.--------chlxwr __aa7o��--------------/--------------------------------------------------------------� / <br /> � '`PhoneAYA <br /> Address--- -------- ------ ------------ --------------0d�4'4�444jo -----------City----- -- - --------- -- --- - -Zip--- ------- <br /> --------------- <br /> Contractor's Name______ . _ L_,._.,?=r1_ _L�_Cr_ ___-----------------_--------------_License #__cA "4oUhone._X_t5__9P426_-jl <br /> Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court [] <br /> Motel ❑ Other------- - --------------- ------ <br /> Number of living units - Number Brooms__ _ Garb in <br /> Water Supply: Public Systemcf..name------------------ --- - --- - ------Private <br /> Character of soil to a depth of 3.feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam 6 <br /> Hardpan E Adobe E) Fill Material_-.________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.) <br /> NEIN INSTALLATION: (No septic tank or seepage pit permitted if public sewer is9vailable within 200 feet,) <br /> 6-X57 ------- ------Liquid Depth._�� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size _ _ ___ _ --------- <br /> Capacity/--!;:2 <br /> ____ <br /> Capacity dv'Q__-__---Type '; M ts-------c� -- .-- <br /> ------ -- -- - ----- -- p '• -- - --- <br /> Distance to nearest: Well_._L. U___ _--------------- �Fout;Co ......--------------------- <br /> tat l�etngttJ.___ O �'._ <br /> 'D' Box ______ Type Filter Material XA,1Y.Qepth Filter Material _2_17---- <br /> ---------------------------- ------- <br /> Distance to nearest: Wet `_..._ - r - ' " Property Lige- <br /> SEEPAGE PIT [ ] Depth- ----- -----Diameter---------- --------Numl3 ---- --- --------------------- Roo Filled Yes ❑ . No,❑ <br /> Wafer TableADepth---------...ems.. __. _- --------Rock Size_ --------------------------- ---------------- <br /> o Distance to ne4rest: Well t - #ion;'-. .^� P e <br /> REPAIR/A VlTION (Prev. Soactitation Pee nit#.---------- ------------------------._- ----------Dote-----------------------------------­-- <br /> Septic <br /> ----- ----- ------ - --Septic Tar"pecifyA;gj en#s '- � e <br /> `-- -- -----------------------------------------w--------------------------------------------------------------- , <br /> Disposal;H (Sp <br /> e.(S e," Re uirements ;' ------------------ , ----------------------------------- <br /> --- - ----- -- - ------- - - -- -- - - <br /> q <br /> 4 <br /> fa - - -- --------- -- •- <br /> �r <br /> �#...' <br /> •---- ---r-- ' ----- �,n'- -------- ------.----------------------- ------- -- -• ----- - -------------------------------------- ------------------------------------------- ------ --- ---- <br /> }�< (Draw existing and required addition on reverse side) <br /> I hereby certify that l have prepared ifhis appliQglon and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Ldws, and Rules., the San Joaquin Local Health District. Home owner or licensediagents <br /> signature certifies $44%1lowing: _...__ <br /> "1 certify,. t. or me rk ftt1P vhie#► this I3ermit'is issued;I sha11 rioi, at <br /> to become sub[ec o aw' Compensatron laws of California,, <br /> Si ned____ <br /> By............... ------ ---- --- ------------------ ------ - --------------------------- <br /> R-----__Title------------ ----- ----------- -------- ------­--- <br /> If <br /> --If other-than owner) <br /> FOR M <br /> "! SE ONLY 1 <br /> I APPLICATION ACCEPTED BY_ --- ---------------------------------DATE----_ _£ v-f•�`-2 -- <br /> DIVISK)N OF LAND NUMBER -- --- ---------------------------------------------- -------------------------------------DATE <br /> ADDITIONAL COMMENTS--- ----- -- - --------- -------- ------- - ----- -------------------- - -'-- -- ------_ ---------------------- - ----------- <br /> ______ ________________________ _____ _______________ _ __ ________________________ ___________________.!ti_-___ -_______________-____ ____._____--_____ __ __________ ___ _--___ -__-__--__._. -__._- <br /> ......... ........ -___ - ..___ ___._ __ ._-. ___ ____ _ <br /> . __.._._ Dui,;,�..__ ___ - •• <br /> Final Inspection by '' — <br /> eH rg 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas zib��RF,47/76 3r.V <br />