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FOR OFFICE US : /APPLICATION <br /> FOR OFFICE USE: <br /> FOIL'SANITATION PERMIT <br /> ----------- <br /> {Complete in Triplicate} Permit No.1�~-!!_L.3 <br /> A Date Issued_.l,,�-_/-f_,2r <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 /> JOB ADDRESSILOCATION--.d=4 �� :1 1< � -�' ---- ----- '- --------"CENSUS TRACT----------------------- <br /> 1 <br /> Owner's Name-__-- - X ---- P one-- ---------- <br /> Ad dress- <br /> ��-Address- al-I' ( +. --City � C ;�' ------- ---------- ----Zip------------------------- <br /> Contractor's Name.-.0 59--- --- -- !' -•-----------------------------License # Z _ ___-- --- Phone ___-- <br /> f 'fie% <br /> Installation will serve: Residence ❑ Apartment House.❑ Commercial [vi!•Trailer Court ❑t , <br /> I Motel ❑ Other --------�---------- __=�'��-- <br /> € ` , <br /> Number of living.units-------------------Number of bedroom s_._._.___:.=__Garbage Grinder..---._:-----Lot Size------------------------ `- -------------.--------------- -- <br /> Water Supply: Public System and name l--------------------------------------- :. ------------ =` ------- ` --------1,77N <br /> -----------------------Private <br /> Character of soil to a depth of 3 feet: k Sand !� Silt❑ Clay ❑ Peat❑ Sandy Loam d Clay Loam ❑ <br /> >, . _ <br /> Hardpan ❑ Adobe ❑ Fill Material-_"__,______If yes, type--------IJ------1--____- <br /> (Plot plan, showing size of lot, location of system in relation to,wells, buildings,"etc. mjst be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tarik or seepage pit' permitted if public sewer is available within 2.00 feet] h <br /> PACKAGE TREATMENT ' J + ------------------�T qI + <br /> { 1. SEPTIC "[ 1 Siie--�G.- -�------- ' -----�-- Li uid Depth �-- --- ------- <br /> Capacity.-)200 <br /> Ca adt Q_-__--_- T e5LhTc- Material y1'lQYL_-_..- No Com ar menu___ <br /> P Y - YP P ;4-------------- <br /> .....Distance'.to.nearest:.Wel!__ G__ �'__1 ------------_._.___Founda`fion._____-_�_______^ ___-=Prop.�L.ine__2�__ �----�___. 3 <br /> 1 i t � <br /> LEACHING LINE. [:1 No. of L•ines__._,_1__--------------------Length of each line,.__�0gkA�T_.___.-_-____"Total Length ) -_ '---_----------------- <br /> L <br /> ___.____________ R <br /> 1+ [ v <br /> ,Distance to nearest:Filter <br /> �Qial��-�'-----Fokundation..i'Iter-Mater�al`-1�---------- --"- --�---�'------------- ----------_-----=--r—'. <br /> t YP Z P T - . <br /> _-. <br /> Property e- -ZdA-- ---• <br /> SEEPAGE PIT [ ] Dep#h___'----- - --Diameter-.-------------"___.Number---=-- r .Rock Filled .Yes ❑. No� <br /> ' W. ate�r Ta a Depth---------------------'----•"------ -----•------' <br /> ------------Rock Sizer'---:----------------�----� <br /> -f--.------R-t---------- <br /> Dsance to -----------------------.Foundation--{-----�------- - Pr`pLine----- -- <br /> ------------------ <br /> . . ^- g - <br /> 1 <br /> � <br /> �AR pDDITION ( vsion Pe�mit# ---:- -- ------.Date----- ----- ----- --�------ --==----- <br /> Sepc (Specify. <br /> SP YRequement1 - ------------------------ <br /> ----------------- <br /> - _-------------------- <br /> r { <br /> Disposal Field (Specify Requirements) _ n - <br /> ---- ------- --------- --------- --------------------------------- ----- --- ---- - --- ---- - <br /> } <br /> 0 <br /> -----------=----------- C " <br /> --------------- ----- <br /> '(Draw�ex]sting' and required addition on reverse side) <br /> I hereby certify that II have prepared-this application -and that the-work will be done in accordan' ce with San Joaquin County <br /> Ordinances, State Laws: and Rules and Regulations of the San Joaquin Local Health District `Home:owner or licensed agents <br /> signature certifies the following: <br /> "1 certify that in the performance of'the work for which this permi Wis issued, I shall"not efnploy any person in such manner as <br /> to become subject to Workman's. Compensation :laws of. California.' <br /> I ) <br /> Signed---- --------------`--- -------- ------------------------------ ------ .-.--- ----- --- Owner 1 <br /> Y ' ' _ <br /> g # - ----, - --- --- Title <br /> d'+P.�?t�-moi <br /> (if other Aan owner) <br /> - ("k <br /> FOR DEPARTMENT USE ONLY" <br /> APPLICATION ACCEPTED BY-------- y__DATE "_- - ----- - <br /> 1 = <br /> DIVISION.OF LAN.Q-NUMBER `= --------- - = DATE -- - <br /> -------- - - ---i <br /> ADDITIONAL COMMENTS -'` --------------------------------------------- ---------------------------------..------------------------ .. - <br /> -----i------------------------------------------------------ ----------------------- ---- -- --- ----- ----------- --- ---------------- --_------------- <br /> -----}-------------------------------------------- ------- --------------- ----- ---- - <br /> - -------------- <br /> - - -- ------------------------------- <br /> ---------- ---- -- ---------------------------------------------- <br /> ------ <br /> ---------------------------------- <br /> ----------- <br /> -----{------------ ------------- -------- ---- -------------------- ------------------------------- ----- ------------------"------------- <br /> ----- <br /> ---- -- <br /> ----- � �7 <br /> -------------- ------- ------ ------------------ <br /> Final Inspection by <br /> :-- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />