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i <br /> FOR OFFICE USE: <br /> ----_ 3I APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ------------------------------------------------ - (Complete in Triplicate) f� /%/ <br /> -- - Permit No.--- -- - <br /> This Permit Expires 1-Year From Date Issued Date Issued__ i�,7� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the <br /> I This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> • JOB ADDRE � � � �` � �-•��- .4��. In described. <br /> - _ <br /> SS/LOCATION--_- �_ , ni' L.L S(�[a y- j <br /> c0' <br /> f Owner's Namec "e?! " . : - ----- -------' -------- --- CENSUS TRACT,-- <br /> -7 R <br /> T ` l< GdsTi -- i <br /> ' 1 <br /> -- - --. <br /> __ ___________ <br /> Address_.- _ G -- - Phone - <br /> - <br /> hon _ - <br /> �, ;. 3..,.. i ------ <br /> Cit 4' 1¢ A<-z�. <br /> _. v <br /> Contractor's Name__. a. -----------' <br /> R ------------------ <br /> h_ . �' �, / 'License SEG-S`vG <br /> f Installation�wi II serve: _ ice # ___-_ one--S�3•��f.�I'J <br /> _ Ph' ------ <br /> rt <br /> Residence Motel <br /> House Commercial ❑ <br /> t � Other-- - ="= -------- <br /> .,--Number <br /> ❑ <br /> Trailer Court <br /> Num ber_of fivin• units.._ - 4' <br /> g :,__Number of..bedrooms_:_ -----Garbage Grinder- l-Lot Size------- <br /> Water Acr Es <br /> s <br /> Supply: Public System and name__--:_-_..;_-- ------- _--.._ <br /> € -- - # <br /> Hard <br /> :: <br /> C aracter'of soil to a depth of 3 feet: = 5cind,� •Silt 0 Clay - ----- ---- ----- - ---Private i <br /> y ❑ Peat❑ Sandy Loam <br /> an teripl._..._.-_-"-_lf es ❑ Clay Loam ❑ :. <br /> p ❑ . Adobe 0 Fill'Ma y type <br /> (Plot plan,;showing size of lot, location of system in relation to wells, buildings, etc.must be placed on rev t <br /> NEW INSTALLATION: (No septic tank or see a e > reverse side.) r �! <br /> p g pit permitted if public sewer is available within 200 feet, 7+ <br /> PACKAGE,TREATMENT- [ ] ' SEPTIC TANK [:] $ <br /> Size- r------------ -------------` ---------- <br /> Capacity-.1--- _ ----"--= ---Type- � e CC s!_Material- Cel iv c.. uid De th- <br /> ----_ No. Compartments <br /> • -.,..Distance to nearest: Well__. " y�d ' - <br /> LEACHINGfLINE oundation--'j_--- -- Line-.-- <br /> ---'F 1 n <br /> Prop Line-.-*- <br /> 5—''Ar SC' - � --------- <br /> lees----- '-�-- --t- <br /> [. 1. No. of L Length of each line. _.:__"-_- - g <br /> f^iLT � 3�d Total Len' th.-' <br /> t D' Box`-1---:--Type Filter Materia!__ !_c _- ., ---------------' '� <br /> w. ._. .. , ... : .Depth Filter Material-.__- o <br /> 5. .. „. .. .,. ' <br /> undation__-_/a__ Property Line-----5^-- ------------------ <br /> ------------ <br /> SEEPAGE PIT [ l De th__- Diameter_----------�v--"Numbe <br /> ipance;to nearest: WelL______�_ ,_'________-_Fo <br /> r-- <br /> Water Table D c iz -- Rock 1 Yes es ❑ No�[] <br /> i <br /> eptly - -------------=--------- - Ro k,S' e- <br /> Distance.to nearest: Well_-,-- - - - ------------------ <br /> ------------- <br /> ----------------- <br /> i _ <br /> Foundation ---- ----- ---- --Prop. Line._" ------------------- <br /> ----------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__._- ' <br /> --:­------ ----------Date--. '--- <br /> ------------------------- <br /> Septic f <br /> Tank!(Specify RequirenientsJ...... .......�._-'_.:.,._ <br /> ----1 1 <br /> --- <br /> ld (SpecifRequirements)------- = .,.- <br /> i <br /> isposa! Fie _ "--------------------------- <br /> -y <br /> ----------------------------------------- <br /> ------------------- <br /> t -------------------------------- <br /> -----=--------- [ -- --- <br /> . <br /> ----- <br /> - <br /> raw e - C. <br /> ------------- -------------------------------- __ __ ____ <br /> t;. <br /> exist, grid required addition on reverse side) <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 Joaquin Local Health Dist rict• Home owner or licensed agents <br /> Signature certifies the following: - <br /> ... g s <br /> "I Certify that in the - F•. , <br /> performance of the work far which this permit is issued, 1`shall not employ any person in such manner as <br /> to become subject to .Workman's Compensation laws of .California." <br /> Signed. Som/ <br /> p. <br /> ------------- <br /> --------------Owner <br /> BY sip ~ ' <br /> o er than' -own'--------------------------------- <br /> --- -- ----- _Title_..--------- ' <br /> an-owner) s- ----=-- <br /> i -------- r <br /> FOR MEPARTMENT USE ONLY t �• <br /> APPLICATION ACCEPTED BY-------- -- ----- <br /> - -------------------- <br /> DIVISION ' = = <br /> LAND NUMBER.- DATE:r.: <br /> OF'COMMENTS " - ; <br /> ----- <br /> DITIONAL -- ----=----------- - <br /> - <br /> ---:------DATE- ---- ------------=-------- <br /> ` -------- <br />----------------------- --- <br /> -------------- <br />----------------------- <br /> Final Ins ect-on b ------------------------------------------------ = <br /> p ------ <br /> _. .� <br /> _ = Date. <br /> EN 73 24 ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ II F$S 21677 REV, 7/76(j, <br />