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FOR OFFICE USE: ,. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- : _, ?Q-5 0 <br /> (Complete in'Triplicate) Permit No....... ....... <br /> k _....-----•--------------------- ----------------- Date Issued__.6/1:3/v <br /> I <br /> ..................• ........... - .................. This Permit Expires 1 Year From Date Issued <br /> Applicatiori 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 ADDRESS/LOCATION- -_-".�, .....:.. ..._w_ FICO <br /> _. --------------- ••-------------------CENSUS TRACT------------------------ <br /> Owner's <br /> --------------------- - <br /> : . ... ass.. 6 <br /> Owner's Name.......... .._ Phone....................... <br /> Address 3 3� S' .... U - - R+1eS 376 <br /> r� ---_.City. . ....... Zip- ........ --- - --- <br /> _.. <br /> Contractor's Name �f�l�°�------------ ---- ---- - .......------.........License #_ V-3 .i_8.... -Phone...�2-J ' <br /> Installation will serve: Residence ®' Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------- ------- ------ ----------- - ------ <br /> Number of living units:....J.--`---Number of bedrooms....�3......Garbage Grinder------_.....Lot Size__--_----aCt: �� <br /> � • w <br /> Water Supply: Public System and name_..-..; -------- -------•----- ..........._.:--.f" ------........ . ---..._:---- ---------Private, <br /> �. -- <br /> Character of soil to a depth of 3 feet: Sand ® Silt❑ Clay ❑ Peat ❑y Sandy Loam R Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ! <br /> PACKAGE TREATMENT [ J SEPTIC TANK 10 k 5 X �- Liquid Depth.....................-_._._ <br /> Capacity..-I aG�? TYpel-'--MQt@rlal-.--CP:Yl4N No. Compartments......... <br /> . . <br /> Distance to nearest: Well__.�_40.0.1.. ._:..Foundation.......10t............Prop, Line----- ............... <br /> LEACHING LINE ( � <br /> of,lines. . ........ ........ :.. Length of each line- --... -_--------_--__-..--Total Length ---------------------.----..----------.v <br /> 'D' Box:---..._...Type Filter Material . ... Depth Filter Material.........-----------.-------............................ <br /> ..--_--. <br /> I t �' <br /> Distance to nearest: WelL--'-- ^-_.............Foundation.-.-._..--__--._-__.-- - Property Line-------.---------.__...-----------.Q <br /> SEEPAGE PIT [ j Depth................Diameter_..__t--- ----------Number-------------------------------- Rock Filled Yes ❑ No <br /> `- - -- ------------- ----------Rock Size.- -- ---------..........-....................... <br /> Distance to nearest: Well......._'_ <br /> f ----- ------ - - ------------Foundation.-----------......_._ ..--Prop. Line------------................ <br /> REPAIR/ADDITION {Prey. Sanitation Permit#---------- .. ............... .... .........Date....----:•------...................----.------} <br /> Septic Tank (Specify Requirements)._.../LVSTgII--- ---=---I }( �t ' "F e l �'fR _ . .. it'.c� �Tu �. 'j��'�+- --.. <br /> ------ <br /> Disposal Field (Specify Requirementsl...._?'rp .. .y _FT.....5.y.S E"!--------=---------- <br /> ------------------- ------------------------- ................ <br /> -----------•------------------------------------ .........• •----t--`--= ------•-••-----••--------....-. ............ ---...-----------..... ---.. <br /> {Draw existing and requited addition on reverse side) <br /> I he certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> e! t, <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 /> "I cern that in'the <br /> certify performance of the work for which this permit is issued, 1 shall' not employ any person.in such manner as <br /> to become subject to Workman' Compensation laws of California." <br /> Signed ........ Owner ' <br /> By.. . T�------------ -- ------•-- - .....Title........ ................. <br /> (If oth r than owner) <br /> FOR EPAR T SE ONLY <br /> APPLICATION ACCEPTED BY /I,� . ... . ---- . ..... DATE �3 ..7..9...... <br /> DIVISION OF LAND NUMBER...___--- <br /> - -----••- DATE - -------- -------- <br /> ADDITIONALCOMMENTS------------- --------- ------------------------------- ------------------._.-------.....---- ..... <br /> ---------------- .............. ...... ....------ ---...--...... �:.._.. <br /> . <br /> - - .. ............... ... . <br /> --- -------------------------------- ................ _-------------------------- ------------------------------------- - ----------------------- <br /> FinalInspection by:.- --. F------------------'------------------ --....------------------------------------ --Date.---------------- - ----------­.­ <br /> EM 13 2A SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 216777/76 3M <br />