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ri FOR OFFICE USE: <br /> FOR OF.FICEvUSE: s APPLIG�ATION FOR SANITATION PERMIT <br /> {Complete in Triplicate) <br /> Permit No.-_�-�'�----- <br /> -------------------------------------- �_ -v_ Date Issued_ 6_r :_7J <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 wi.t'h County Ordinance No. 549 and existing Rules and Regulations: , Y <br /> . CENSUS TRACT <br /> `JOB ADDRESS/LOCATON �U <br /> ---------------------- -------Phone <br /> �76�---------- <br /> : G------- C{dw <br /> + - -- :, z$ `Owner's Name-=----- - -----------------City.-,51- <br /> Address ! p - - ----LicenseContractor's Name f - i . , <br /> Phone"3. <br /> I Installction.will serve: Residences; Apartment House.❑ Commercial ❑ ~Trailer Court ❑ ? } <br /> t -Motel ❑ Other: <br /> Number of living units:______ ------- of bedrooms_.__�------Garbage Grinder........_:_Lot Size-------_%•--_ - ---------------------------- <br /> WaterSupply: Public System and'name----=-----------------:----------.---------------------------- ------ ---------------------------------:---__.---- ------t-------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material_-___-----_-If yes, type_._________--___ <br /> (Plot plan, showing size of lot, locationssystem in relation to:wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION:— (No sep c't riR'or seepage .pit permitted if public sewer is available wrt&iri 200 feet,) <br /> TANK ..... Size-- - - - Liqu Depth. <br /> PACKAGE TREATMENT [ ] ii"SEPTi ['] ��' id D ---------- <br /> Capacity—$— <br /> -- <br /> ,, Ca acit - -'�- Type-_e-� `1+Aatariai--------- f-' ___-No Compartments ---w' . ------ -- <br /> F i S <br /> nearest:.Well. _..___ .-- Fou ndatloAt Z;— __ , _.Prop. Line _.----- --- <br /> Distance-JoP j <br /> t i 1i <br /> LEACHING LINE [J Noof :Lines-!---. -------- -- _-__.Lengt-h of-each ling __- -__ __ Length f------'-------------'-____-i___-___-___04 <br /> j D`f3`oX ___ _.Type Filter Material: __ ;.____ ' Depth Filter NMterial� -_____ _ _ 1---- <br /> DistonCe to nearest: Well]-------------- :.FRou nation_ _5__ - - Proper Line-___---- - <br /> .4 <br /> �tY �-- - -- <br /> " SEEPAGE PIT [ :] ._pepth-------- -- {-Diameter- ------------------Number--------- ----- €Rock Filled Yes ❑ No <br /> > <br /> + ",.•.. ,�,�: <br /> l <br /> � - <br /> Rock �S <br /> z Water Tade-Depth _ - _ - = r �= <br /> , ~. <br /> ..-tPro p�.,..Line �_� <br /> � � <br /> - <br /> S Distance;torarest: Well-�------------- --------- <br /> - ---:Foundation-- - .. -..----------- ] _ <br /> REPAIR/ADDITION (Prey. Samtrtion Permit#___ - _ __________ __________� -----.Date` -'----- --- ------------------ <br /> Septic <br /> -----------Septic --------------------- <br /> F <br /> Tank {Specify Requirements) �= ----------------=--- ------------ ----------==-=------=-.------------- -- - ----------------=-; <br /> Disposal Field (specify Requiremer[ts��----.C �--- �3�? ---- XF�' -- ---- s } <br /> y � ------------------------------- s ,� Cay ads <br /> IL <br /> [[[ .. <br /> =%�` <br /> } ------------- <br /> ------------------------------------ -------------------- <br /> I . <br /> r , <br /> p = t'``Draw existin `dnd re wired a"_dd Pion o—`n reverse side) <br /> hereby certify that I have prepared his'application and that.the work will be done-in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules -land Regulaticns_,)ofnt a Sarijp quip Local Health District. home owner or licensed ng nts <br /> signature certifies the following: Y <br /> k "I certify that in the performa�---"nce'-6TZthe'work for wFiicti this permit aissued,-1 shall not employ any �rson in suc nne�rf as\ <br /> to become subject to WarkMan'§r�dmpensation laws of California." ` <br /> Signed ...__._ ::Owner _ �`� f <br /> .. -i <br /> Title <br /> BY ----- - :. . <br /> (If other than ownere � <br /> } FOR DEPARTMENT USE ONLY l "[ <br /> APPLICATION ACCEPTED: BY=---- ---- 'L_ __:T-- -------------- <br /> = -; DATE - <br /> DIVISION OF LAND NUMBER..-- _---- ------ ------ <br /> ------ DATE <br /> -- ----- <br /> A ITION CO MENTS. aeQ -______ - � � ""� 1' .- <br /> --------- - - -- -- ---- ------ ---- - =- = ------ = ----------------------------------------------- - <br /> ------------ ------- -----------=-------- --- - -- ---------------------------------------------------------------•------- ---- --- ------- <br /> ---- ------ ------ ----- ------------------------------------------- ----- ------------------------------------------------ ------------------------ <br /> ------------------- <br /> Final Inspection-by= -- ---------------------------"---_-=-`-------------- "---------_----- - f <br /> tr+ 13 24 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 RFV- Ina 3M <br />