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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --- Permit No.� <br /> --------------------------------------------------- - <br /> (Complefe in Triplicate] - - � <br /> YA/y;p --------------------- Date lssued.-y-,2s'-=.fir <br /> "'t IF 1-------- ------------------ -- 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 Ordin nce No, 549 and existing pules and Regulations. <br /> JOB ADDRESS/LOCATION --- -:7 '' '-- ' Y�{+ / '-------- --------------E--- � �••_ CENSUS TRACT = � <br /> h <br /> Owner's Name--------- 1� rro,/e-a`�: ---- ------ -------- Pone } <br /> Address--------A'�T X- --- %-Y-�[�~' .-------------- ---- ----------------- --City-:-1-4 C ---------- ---------Zip-------------------------------- <br /> ov <br /> Contractor's Named m#_44A.�*a'FtP----5 � '�'# '^��"�'• Z*-'-� r License ,# }.�. _3 = Phone�#l.i�=.3 �� <br /> Installation will serve: Residence X Apartment House ❑ -Commercial ❑ Trailer Court❑ <br /> ' Motel ❑ Other - ..-- s <br /> Number of.living units:.___ <br /> --------Number of,bedrooms__—.�_ Gar.bage Grinder'-� <br /> ' __Lot'. el_��_���"'�E_7,�f�_�11i_141_ G�"-�j-73�J-/T i <br /> Siz= � . --Private <br /> Water Supply: Public System and name- := ---_:_.--=------------------=-------------=----- ------------ --- <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> P ❑ . r r-----, yes, type---- ---------------- ---------- <br /> [ Hard an Adobe Fill Material-_.- If e <br /> [Plot plan, showing size of lot, location of system in relation to:wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank-or seepage :pit permitted if public sewer is availpble within 200 feet,) 1 <br /> PACKAGE TREATMENT [ } SEPTIC TANK " Size-__ /- - --- �.�-�Q�� } :_liquid Depth.--�'4c__`_------------ <br /> e <br /> Capacity �-A a'd TYPe Material--------- -No. Compartments .--=-;--- <br /> s # • <br /> Distance to nearest.Well.`----- -+v -r----•.---,-.----- Foundation-----1-a--f-----..---_""Prop. Line-----�' '---'------- - <br /> l <br /> ` t 1 r �- <br /> LEACHING_ LINE Q(T No. of Lines_- Length of each line.:-,_____ `- _,. _,Total Length __.._.2. G_._,________:----__- -- <br /> �l <br /> s ,.r Y 4 .• <br /> ' z'D' Box -:Depth Filter Material __ -- - _-_ -_-_f <br /> 3 -- - - <br /> I -pistance.to nearest. Well_-- .___��� _-_ Foundation____. 3.__ ___.__ Property Line -�- _ ` <br /> �. -+.• <br /> SEEPAGE PIT [ l Depth __.!------!----Diameter .._____ -- -" '_..Number _._ <br /> ---- ock Filled Yes ❑ No <br /> eji� <br /> --1 .4 '� <br /> x0 <br /> Water;Table.Dep'th ---- - �_---- -- ----------- <br /> u <br /> - -- , - - --------------------------- <br /> ----- ---- -- -----------------� - - <br /> - R' k � , <br /> l [} t Distance to nearest4Vti/ell_ <br /> -- - '- -'=--' --------- -Foundation.-°------'---------------.Prop. 'Line----------------------- ! - <br /> t <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------=--r--------------------------Date-._--'------- - ----- `•I <br /> Septic Tank (Specify Requirements)ZA oQ ---------- ° -S <br /> r , f . <br /> l Disposal"Field (Specify Requirements)----.7I!q"—X� � ' � � ' �__ �.�.E`S--_-. .Y_._L__ ----- '. <br /> ---- -- L- d-- ,i <br /> k:�""�..L :--- [ <br /> - ' [Draw-existing and required addition on reverse sidej'� i <br /> f <br /> I hereby certify that I have prepared this application and that the work-will, be done in-accordance-with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Jle"aquin LocalHealthDistrict. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to bec5L,to Workman's Compensation laws of California." - <br /> [: e: <br /> Signedcaner <br /> T - ------ <br /> - .___.------f_-------------------------- -- -- -------- _ ___ <br /> itle ---- <br /> } s(lf other tFian"owner} <br /> - FOR'DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEC BY-._-- " .' —� --- - <br /> --------- DATE <br /> DIVISION OF LAND NUMBER ----- t.. = '---------=------- r -----------.---DATE------- --- ------------- . ----------- <br /> ---" ---"--- - <br /> ADDITIONAL COMMENTS------------------- - ---- <br /> ------ <br /> - ---------- ------------ <br /> - - _______ __________________ t—, -Ir <br /> ___________ _ <br /> ----------- <br /> ------------------ <br /> --._ -- ... <br /> • -- ----" ---' -- L <br /> -- '---- � ate <br /> D � <br /> Final Inspection by,----- _ _ "` ---- --- <br /> ---- - -- ------ --- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F 21 . '/76 3M <br />