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FC- R -� ICE USE: <br /> � {- ,� APPLICATION FOR SANITATION PERMIT- <br /> --------- <br /> __ . w .-, -. �_a.. a .. Permit No: <br /> -------------- �� <br /> \'r', (Complete in Triplicate) [ <br /> ---------------- ------------------------------------ --- <br /> i <br /> ---------------------------------- --- <br /> i — ' Date Issued S_.__ 7_-7 6 <br /> -------I---a__4_ ---- ---__\,_,(---__-____-- This Permit Expires 1 Year From Date Issued <br /> - f <br /> Application is,hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. Thislapplication is made in compliance with Co nt O dinanc N 549 and ezistin Rules and Regulations: <br /> JOB ADDRESS/LOCATION�CZO'�_. -�" "5rc/_�_�__4✓�__I_--/�I TFC ____.__._ CENSUS TRACT __ �t�/__,____ <br /> ---------------- -- -- <br /> Owner's Name <br /> ------ -----i -!1�------PhoneW; _-'�-__��---- <br /> Addre55 ......, 3 -, 1e 'i✓s L�7C `:_ -SYS r�►/ ---. �-Ci �9i1i7 C - - -- ------ <br /> F � , <br /> r ( [ e <br /> Contractor's Name -----T �-r�, --------------------------------------------.---:--=_. .License *=2,5;s�+3�0 Phon_e�a2_��__-`_�l_'_�,�F <br /> Installation will serve: Residence [�artment House°❑ Commercial :❑Trailer Courtt;❑ <br /> + Motel C] Other -____-- 1 i i <br /> ------ - <br /> Number of livingunits:.__ _/___.___ Number of bedrooms 6-r'i 1 P'. -_- �:� _...:__: <br /> / �______Gdrba e' ander _."'_`__ Lotr ize ___ ____ <br /> 9 � <br /> { A{ i- - , <br /> Water Supply: Public System and name -------------- ----_--}-------------___._:-_'-----------------------e__ ----Private <br /> Character of soil to a depth of 3 feet: Sand'�ilfi❑ Clay Eft Peau❑ Sandy Loam ❑ Clc#y Loam;❑ <br /> y.Hardpan ❑Adobe-DFifl NI' — ----- <br /> aterfnt =fs�ty -.--- --- --� - <br /> s er F t I F P <br /> •.�*� <br /> (Plot,plan, showing size of lot, location of system in relation to Wells, buildings, etc.) rriust be placed on reverse side.) <br /> 1" I ; i ) # 1 O 4 <br /> PACKAGE L ATION: (No septic tank or seeps a pit permitted if public+sewer is available within 200-feet,) <br /> NEW.INSTA .. ,;,, • i� I \ ; <br /> EATMENT [ ] SEPTIC TANK'[ Size' -- _ -------------------- i __ Liquid':Depth ...... i <br /> p y __ yp - ---- Material����r,F` Nb. Compartment ---------------------- <br /> Distance <br /> Ca acit �a� T e� -------------------- , <br /> Distance to nearest: Well _ Q___________________ __Foundatio ---- Prbp. Line <br /> LEACHING LINE [ No. of Lines ______________ <br /> __________ Length of each line___ _'-7Si� al, Length _.__----------- <br /> - -D'-BoxF�f .-Type-Filter Material oead< A.'Depth,Filter l'teri'al _�� --------- <br /> Z --�_._- �t <br /> t f i .'I p tY _ / i �k <br /> I Distance to nearest: Well _ �_____________ Foundation _ 4n-_____?-__ __ Pro er Rine.,-- <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter __________.___. Number}______--------------' Rock,Filled Yes :❑ No <br /> Water Table Depth --------------------------------------------1_1 Rock-Size - <br /> Distance to nearest: Well ---------------------------•-------- ='-Ffundation ---- --- ----------- Pop. Line -------------- <br /> ) 4 <br /> I <br /> REP pRIADDITION(Prev. Sanitation Permit# - --- •- - 1D-- �_te <br /> . - <br /> Se ------------- ................... <br /> - - --- ---- ----_-- � ----:;-------. - ---;--- <br /> # <br /> fw ------------ --_-------------�:-;� - <br /> Disposal Field (Specify Requirements) ---------- ----------'-- 4 _i--------------' •--- ---------- -i- <br /> i _ <br /> ------------------------------------------------------ --•-- --------------------------- --------- <br /> l: <br /> • <br /> (Draw`existing-••and-required addifion=on-reverse-side) r - - - <br /> I hereby certify that I have prepared this application and than the work will be done0n accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of'`the San Joaquin Local iealth District. Home owner or licen- <br /> sed Agents signature certifies the following: t r, <br /> I certify that in the performance of the work for which this permit is<i§ ed,'I shall noteimploany person in such manner <br /> asIto�become subject to Workman's Compensation aws`of California." o <br /> Signetl -- -----------------------------3-;-_k,4° ----------------------------- Owner <br /> BY!-------- ` � "`-'-fi�tle=._ 1E'r/✓F�Q--� £ id <br /> - f ------- <br /> (If other than own <br /> i t FOR DEPARTMENT-.USE ONLY <br /> APPLICATION ACCEPTED BY <br /> = --, DAT;: �_s� `=1 p 'f <br /> BU,[LDING PERMIT ISSUED ----------- ---------I -- -� - �==---.`D.A.Te-` ------------------------------ <br /> - ---- <br /> ADDI 'IONAL COMMENT ----- --- - ------ ------ ------------ - --------------`------ --.--------------------------------------------Q y <br /> ----i-- �--- ---- - -------- }'» <br /> t ---------- -- ---------------- --------------------------- <br /> ----------------- ---------- - -------------------- - <br /> ------ -- - -- --- --- ------ - --- <br /> ----- ----------------------------------------------- <br /> Fina1!Ins ection w' ._____Date _._._. _______ <br /> p ------- ----------- <br /> SAN JOAQUIN. LOCAL HEALTH DISTRICT _ <br /> E. 1- '68 Rev. 5M + <br />