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1`00bf`FIC� USE: <br /> FOR d1FFIC`E USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> . ...........................................-........ Permit <br /> (Complete in Triplicate}: <br /> ......................................................... <br /> Date Issued.../7��ZY7��7/ <br /> ..................... ----------------- This Permit Expires I Year From Date Issued <br /> Application is hereby made to.the Son Joaquin Local Health Districl for a perm-it-to construct ani.install the work herein described. <br /> This -application is made in compliance with County Ordinance No,,.549 arld'ixistlrl ides and Regulations: <br /> n K les a <br /> 12, <br /> JOB ADDRESS/LOCATION It 6Z <br /> ,y ... ..CENSUS TRACT.. ---- - <br /> - ------------------ --- - <br /> Phdne- .�-------- <br /> -Owner's Name ---------- <br /> 4��-- ------------- -- -------------------------------------- <br /> ------- ..............ZIP--- <br /> Address................ _qll- - --------- ------------- -- ----------- ---- <br /> Phone-: .-.-:----------- . ........... <br /> ...License <br /> Contractor's Name............. .......... ...... ................... <br /> Apartment House,E] Commercial Trailer Court <br /> Installation will serve: Residence <br /> enceX ❑ <br /> Motel ❑ ----------- ------------ <br /> Number of living" units:-------- ---Number of-bedrooms_3_ -Lot,Size------:470/y'/ .......... .......... <br /> Water Supply: Public System and name-:.----- ------------ .... ... --------------------------Private <br /> ❑ <br /> ------------- <br /> Character of soil 'to a depth of 3 feet; Sand [3 Silt EJ Clay 0 Peat-E] Sandy Loqm X Clay Loam 0 <br /> Hardpan ❑ 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 /> NEW INSTALLATION: (Nd septic tank or seepage pit permitted if public sewer is available within 200'feet,) <br /> PACKAGE TREATMENT SEPTIC TANK .........Liquid Depth---------- --------- <br /> Capacity.....................Type-_­.-_-._ ... .... ..Material--------- Compartments _.--------_-- ----------- <br /> i — <br /> Distance to nearest: We�]]-­----------I... ....­­_­---=-Found.cition,J ........Prop. Line-- - Qc <br /> LEACHING <br /> ine--------- <br /> LEACHING LINE No. of Lines ----- ---------------......Length of each line------ ----------- Length ........:........._........i......... <br /> 'D' Box..... ......Type Filter Material....................Depth Filter Materiafl.,=,,�!...__---------- ------------------------- ------- <br /> PropileTty Line.---..._..---.-------.---........ <br /> Well----------------- ....:---...Foundation.--"' ­-------- ----- -------- <br /> Distance to nearest. <br /> SEEPAGE PIT 0 Depth...-..._ Diameter----- .... ......_ Number------ -------------------- <br /> 4 -Rock Filled Yes ❑ No <br /> Water Table Depth.------------- . ........ ........ <br /> ----- ----------------- '�.....Rock-Si-ze------------------ L_ L <br /> Distance to nearest: Well _ F66n dd_ti P-n <br /> j, _7' <br /> .........*.Prop. Line-_... ---------- <br /> m --- .. . ---- Date_-. +,---- ------ ------- <br /> REPAIR/ADDITION - <br /> Septic Tank (Specify Requirements)......... .. ... ....... ---------------- <br /> .... --------------- ...... ....... <br /> ------------ ------ --------- <br /> Disposal Field (Specify Requirements).... ....... <br /> ------------ ...... ---------- <br /> e�D <br /> ------------- - <br /> ....................­_ _V _. - . - ...g_ X" /0--d <br /> --------- 40- -C , .�/_, <br /> - ----------- --- -- ---- -- ----------- -I............­ -------- ----------------I--------- .... ----- --L...... <br /> (Draw existing and required addition on reverse side)'A <br /> I.hereby certify that I have prepared this application and that the work-:� ill be done inlbccordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San,Joa ct�ujn Local Hecdth.bistrict. Home owner or licensed agents <br /> signature certifies the following- <br /> certify that in the performance of the work for which this,FiFe'rmit is issued, I'shall notemployany person in such manner as <br /> to become subject to. Workman's Consation laws of-:California." <br /> 'Signed)(. OP P, _� I <br /> -- ----- ---Owner <br /> By/_............. ...... ......... <br /> Title ------- ............ ............. <br /> {If other than oivn6r)' <br /> FOR DEPARTMENT <br /> USE ONLY <br /> APPLICATION ACCEPTED YY.,!.:. 1900&,/---- -- ............­ .......DATE 7-7-.. ------ --------- <br /> .......... <br /> DIVISION OF LAND NUMBER_. ------- ---------- ---------- .............-.,-,DATE.... ........... <br /> ADDITIONAL COMMENTS.- ----- - ------- ------------- - --------- ------------------- --------- . .......... <br /> - - ---------------------------------------------- <br /> ..... --------- ------- - ------- ......... ........ <br /> --------------- <br /> .............. ........... <br /> -------------------------- <br /> - <br /> ------------- ........... ---- -- -- --- --------- - ---- ------ ----------------- --- ........... -------------------- ­------------ <br /> -- -- ---------- <br /> ................. --------------- ---------------- ---­--------- ---- J/ho <br /> ------------- ---------------- --- <br /> FinalInspeciioniby:. ... . ..... ------- --- ------------ -----•-------------------- ------- --------------------------Date <br /> EH 13 24 SA.N JOAQUIN LOCAL HEALTH F&S 21a77 REV. 7/76 3M <br />