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� A <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> } Z; • -�s��/ APPLICATION FOR SANITATION PERMIT , <br /> (Complete in Triplicate) Permit No.._.77~�� <br /> -- - ' <br /> Date Issued--. = x"77 <br /> # --- =----- -- _. This Permit Expires 1 Year From Date Issued <br /> �i <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 N6/549 and existing Rules and Regulations: li <br /> r JOB ADDRESS/LOCATIONR <br /> f <br /> _•- ---- - _ CENSUS T ACT. <br /> Owner's Name.' <br /> f s. y. r---�--.-. ----------------------- <br /> -----..f -- --- -- rt <br /> - - ----------- <br /> ------- � -- . Phone <br /> - --- - <br /> AddresCit <br /> ,- - ------Zip._._.: <br /> Contractor's Name 1t�u�� li<,�:�c----�.[-- ------------License #_3_�_Kz_�_� Phone <br /> Installation will serve: Residencey y" <br /> [ Apartment House ❑ Commercial ❑ Trailer Court Q i <br /> .. ..�r_..,t.,.. Motel L Other---'.----------------- <br /> ---- -- ------------ <br /> i y <br /> Number of living units:--------- ------Number of,bedroom s-_.r_._Garbage Grinder---------------Lot,Size......`._.-------------- <br /> -------------- ---- <br /> ! • <br /> o Water Supply: Public System_ and name ---------------------------- -------=------------- ---- --------------------- ---------------------- <br /> :Hardpan ----Private <br /> f Character of soil to a depth of 3 feet: SaE] E] E] 0 any 'Loom Clay Loam L�/ <br /> nd Silt Clay Peat Sd <br /> ❑ Adobe ] Fill Material....___._ ..___If yes,type___________________ <br /> l (Plot plan, showing size of lot, location of sys�te��m,✓✓in-relation to.wells; buildings,-etc, must be placed on reverse side] <br /> NEW INSTALLATION: (No" <br /> 'septic 'or-seepage .pit permitted if public sewer is avdilab_le within 200 feet,) <br /> PACKAGE TREATMENT [ .� SEPTIC TANK'. [Y)/ Size_ Tf S '_ 'I � <br /> '1 ��a�---� � ' �-----' _-Liquid Depth- �---�-- <br /> Capacity._1 :�'d-_: --Type--- %Mater ial---f — -No. Compartments--=' --- -----------------= <br /> �* <br /> )'Distance to nearest: Well.... .,_.�' ________ ______________FounddtionR.__ `�a__,_.- Prop. -Line S_.__A <br /> LEACHING LINE ��[ 'No. of Lines-' ____�_ ' .Length o� f eachline n -- t' �� r <br /> w - _ = Total�Length = i <br /> r <br /> t t ! ^� Material s 1u ,,; <br /> . -------------- <br /> D' Box -.__..-TypelFifter __.__ _R_. _Depth Filter Material_____ t ' <br /> ?.. : . .. ,.....,,� --- - -------- <br /> Distance to nearest: Well.'__ 19_d_':r-----------Foundation_._ __ 1.b. :___Property Line....-r , r _ <br /> _-. <br /> SEEI?AGE PIT [ Depth--- --_ -�1._-____Number ___,-;;- ------------------ t Rock Filled Yes E�/- Noy <br /> Water Table Depth r 1a_" . <br /> ! � � . p ---,--�f,,b--------------------------------------- -Rock Size � 3--- 'F <br /> t Distance-to neare's't:'Well. s ___� -__.;_ _____.Fo6ndation__._. L n -' __-_--.Pro Line.____ <br /> REPAIR/ADDITION [Prev. Sanitation Permit#_'.....::..:...:..: - _------•------Date---_------_-:------------_r :---------:-;-__) "� a <br /> Septic Tank (Specify. Requirements)_._--,-.-_-,-I___._ ' i <br /> ;r ---------------=------ ---------------- ----------- ----- -------- -------- a <br /> Disposal Field(Specify Requirements}_ --------- ---___----------- ---- <br /> „ --------------- ------------------------ <br /> a----- <br /> F ------------ ------- ------ <br /> ---- ---- ------------ <br /> = ---- -----------------------------------------=------------------------------------ <br /> ----------------------------------=------ <br /> . (Draw existing and Fequired'addition�o reverse se);' � " k <br /> I hereby certify that':I-have pre -tired-this application-dnd-that-the-work-will-be-done-in--accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules_ and Regulations of the San Joaquin-Local Health District, Home owner or licensed agents r <br /> signature certifies the following: <br /> "I certify that in the performance of the'work foi: whI4h'this permit is ltsued;`1-shall'-not employ any-person in such manner as <br /> to become subject to. Workman's Compensation- lows of California." <br /> Signed--------'--------------- -- <br /> ------ ------ <br /> I <br /> (If .. n <br /> Y ----------------------------- <br /> --------- --� - - - Title---- --------4- <br /> other than owner . <br /> ' S ., ._.... i..... . . . FOAMENT USE'ONLY . r, <br /> APPLICATION ACCEPTED SY-'------------------ - ---------------- - ------ <br /> DIVISION = R' = DA --� _ <br /> TE ------- --- ------ ----------- <br /> OFLAND NUMBER> -------=------= ----------- --------------=-------- ---- ------=---.---------- ---- -------------------DATE_`----- --------------------- -- <br /> ADDITIONALCOMMENTS---- --------------------;--------------------.------=--------------------- ----- --------- ------------------------- <br /> ---------------- --------------------- --------`-------------------------------------------:-- ----=-------=----------------------==-- ------------------------------- -- 1--------- --- - <br /> =----------------------------------= ----- - - it . <br /> Final Inspection by:= -ate - Date r <br /> - -- ------ -- - _ •------ ---- -------------- <br /> EH is sa SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV, 7/76 3M <br />