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FOR OFFICE USE: <br /> ,, r /�.�o APPLICATION FOR SANITATION PERMIT <br /> permit No. _.___._76"" <br /> -- -- ---------- `' p P <br /> { (Complete Triplicate) <br /> V-0-------- f <br /> Date Issued �_��—_7C1 <br /> This Perrnit Expires i Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District fora permif-to consfruct'and"install the work herein <br /> described. This application is made in compliance with County G rdinance`NoS•49 and existing Rules and Regulations. <br /> r� 1 R CENSUS IRACT ____-_-_ ------JOB ADDRESS/LOCATION ------�$_3/ .. � -Ac ------ t <br /> Owner's Name ��` �y._ ¢_,a _` !* - -------Phone ------------------------------------ <br /> ".. -----• Cit ,nee ------------------- <br /> Address � �T�� -=--�--------------------- ----------- ------ Y r Y <br /> Contractor's Name _.__ ` = -�!' License # _ _ EO)l4V <br /> YL 0 <br /> Installation will serve: Residence A)a tment House'❑f6 mmercial ❑Trailer Court i❑Motel ❑Other -------- - -- - - - --- --- -----Number of living units:--___-_ Number of ��bedroQms __t!/------Gari�age Grinder a"-- lot Size --____________---- <br /> Water Supply: Public System and name _. Ii --- '- d ��f� ---- - -----Private ❑ <br /> I <br /> Character of soil to a depth of 3 feet: San d'❑ Silt El a E] Peat E] Sandy Loam ❑ Ciayr Loam Z] K <br /> Hardpan ❑ Adobe ( iil Material ------------ If yes, type ------------ --------- <br /> (Plot plan, showing size of lot, location ofystem in relatio oto wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permiLdf public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] 3/Size---I---------------------------------------- quid(De th ------------------------.- <br /> --- Li p p� <br /> CapacitY Type - ��------------- <br /> Distance <br /> t _Material---------------------- No. Compartments ------------- <br /> Distance to nearest: Well ______________ ----------- - Total -iprop. Line ---------------.______ <br /> _ Foundation _____________ <br /> Len <br /> LEACHING LINE [ ] No. of Lines ----.1`i____________ __ Length .of ekch line-----_--_-__-- ----- ---- - ,L`ength ,-----.--------------------- <br /> 'D' Box ___.---- Type Filter Material ________'�__-______Depth Filter Material `-________________________________________ <br /> Distance to nearest!, Well ___________-__________ Foundation ______.____T_-_-- '--Property Lurie. __________________ ____ <br /> I ) p Diamet---- 0 I <br /> SEEPAGE PIT --- Number ------------------------ --- Rock Filled Yes ❑ No CWafter Table Depth- ---------------------------------Rock Size -------------------------------- <br /> _____-Foundation Prop. Line ______________________ <br /> Distance to nearest: Well -----�---------------------•_-•- -------------------- p• <br /> r t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- --------------------------- ---- - Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -,0 PAQC--�-----a9l-�= 1� 'r '--------------- <br /> Disposal Field {Specify Requirements) ---___ _ <br /> ��-'�.r ---------------------- ------'------ --------------------------------------------- <br /> -------------------- -------- ------- <br /> -----------II ---------------------- ------- ----------------- - ---------------------- ------- ----- <br /> (Draw existing and required addition on reverse side) i V <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules fond Regulations of the San Joaquin Local Health District. Hoe owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the w k for which this permit is issued, i shall not employ any person in such manner f <br /> as to become subject to Workman's Compensation laws of California. <br /> Signed - --------------------- Owner <br /> BY ------------------------------------ l�l� j&--------------------- Title , <br /> (if other t owner) <br /> r F"ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------- . --- ______ <br /> DATE " ------------------- <br /> BUILDINGPERMIT ISSUED ------------ -- - ------- ----------------------------------------A- e------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------- -- -- --- ---------------------------------------------------------------------------- -------------------•------------------ <br /> --------------------------------------------------- -J------------------------------------------------------ <br /> �--------f------------------------------------------------------------------- <br /> �------------------------------------------------------------------- <br /> • ------------------------------------------------------------------- ------------------ - ------------------------------------------------------------_ - r� <br /> Final Inspection b ------Date __ -�_ :/-(�_.___-____,_- !j <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 '1irl X68= 5MV — • �.� <br />