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`FOR OFFICE USE: _e FOR OFFICE USE: <br /> _ APPLICATION.FG1R SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No.-..7-7r-- _.. <br /> ._.__"___"______________________ ---------------------- ,'* 6-1237 <br /> - Date Issued_______________'_._7 <br /> This Permit Expires 1 Year From Date Issued <br /> f <br /> Application is hereby made to the,San Joaquin oca ea isfrict fora rmit to evnstruct and install the work herein described. <br /> I This application is made in compliance with County OCNiDcnce C& 549 a0dyexistinj_,0yles and Regulations: <br /> WW V <br /> JOB ADDRESS/LOCATION _ _,__- -- 1u��L''----/�.�7---'---- G°---------------..CENSUS TRACT----���--- ------- ---. <br /> i <br /> Owners Name.--- ;19*, . -------- Phone. = (� <br /> Address � rtfv0 ------d-- . ---- ----- ----- --City .-�"-`Gt --------------- ZiP <br /> ___ - - -r: y� ._ r• .. .+ice ,� .}. -• <br />= Contractor's Name...... ----- ' --------------- =------=License '# ------f IFk------Phone- ITS------ ------------- <br /> �- •fes,/....,. ._.y ------_-----.._� ._ ------- <br /> � c.- ;. .i ..«,l.......� .. <br /> Installation will serve: Residence s Apartment House[] Commercial ❑ ;Trailer Court ❑ <br /> ._.. ...,_..; rl'' Otel --------- ------ �., . . <br /> Number of living units:____/-______---N,-umber of bedrooms_iOther = <br /> _,Z.___Garbage Grinderly,0"_-.Lot,Size.----- ___ -f------------------- <br /> I `Water Supply: Public System and:name =- ------------• -- ---------------G�'. - Private' <br /> i -- - .-------- .-- <br /> Chara'ter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑�' Sandyoam< Cay:Loam ❑ <br /> G Hardpan❑ Adobe ❑ - Fill Material_...'_____ If yes„type__.= -- ---------------- <br /> (Plot plan, shows g,size of lot, location of system in relation to wells, building,s,jetc.imusl be placed�on=reverse side.) <br /> NEW INSTALLATION�(No septic”tank yor seepage pit 'permitted f public sewer if gwailable witl)i4200 feet,) <br /> [ } [ � �� <br /> PACKAGE TREATMENT SEPTIC TANK r •� `� Siie-___�__ �-" w-_ ____ _ '`'- _ _�Liquid Depth_________________________ <br /> Vt <br /> I Capacity erial 0. Compartments------ f-------------� <br /> Distance to nearest:.Well.-'-------15'------ -----=------------ Foundation_ -/a.._-----._.__.Prop. Line----- -----------.-. <br /> LEACHING LINE, [ 00 <br /> } No. of Lines,.-___ ---*--------,__,Length ea`h Linea __ `--!4 - :, Total Lin lgth.____.� - ------------------ <br /> ofrn <br /> 4 _ D' Box-4-__ _Type FiltMateriaiC J Depth Filter Mate al__, /._. ____ <br /> _. -�..- ..,.. �` anon _$• Lin ._.. <br /> Distance to nearest: WeILT .- ;- d ,��._ �A___ _ Property e----- -------------------� <br /> -_-: ---:----B+am ter Na, -_____________ G__• . I ' Rock Filled Yes ❑ No❑ <br /> wato� --------------------------------------------------------- <br /> -- -- ----------------------`------_------------------Rock . . ........ <br /> - . ---=--------- -------------------- (0 <br /> 'Distance to nearest: Well---------------------------- ------ ----"Foundation- .-------------- Prop. Line--------:--------------"""-. <br /> REPAIR/ADDITION (Prev..Sanitation Permit#:.__._ -_-:-"__________________-------_bate------._------------------------------ -�}, <br /> } ¢fit$-�� a� <br /> Septic Tank (Specify Requirements). -=--- - I ) , <br /> --- <br /> Dis osal Field (Specify Requirements)__- �y��+ s. � <br /> _ - - ------------ ------ ----- -------'---------_-- <br /> ---------------------:---------- --=----------- ----------- --- - --------------------------------- --- --- ---------------------- ---- ---------- <br /> ----------- <br /> --------------=------ --=---=---------------- - --------------------------- ----------------- <br /> (Drawexistin'g and required <br /> - <br /> addition•ori'ri:verse 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 District. Home owner or licensed agents <br /> :signature certifies the following: <br /> "I certify'tha in'the performance'of:the work for which this permit is issued, I shall not employ any person in 'such manner as <br /> to become s bject to m n's mpen�ation laws:of CaliFornia.'.' <br /> i - - <br /> Signed - --------------- --- Owner <br /> ,_. <br /> gY - - -- ------ ----- ------' -----'-------------------- -- ---- -- ----- --- - _ <br /> Title y <br /> j . (If other than`owner) <br /> FO . EPARTP ENT USE ONLY ¢' <br /> APPLICATION ACCEPTED BY = t =----------------------- ---- =----------- f" <br /> DIVISION OF LAND NUMBER --------- ----------= ------------i--=---_------------=----- --- "�`t"" .__-------------.DATE-------------------------------------- <br /> ADDITIONAL <br /> ------------------ ------------------ADDITIONAL COMMENTS ----- ---- ------------------------------------------------------------ - -------------------- ------------------ --------------------- <br /> } '. __ _ <br /> } ------- ---------------------------------------------- <br /> ' - --------- --- ----- <br /> ----- ---- -- ------------------------_ --- - � -y <br /> . ----------------------------------------- �; <br /> - --- 4 ------4-------------------- <br /> i Final Ins ection b .:4'�___-�-___-:- . ..- .- Date.=- � <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV.,\/76 3M <br />