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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION`PERMIT / <br /> Permit No..-.�-��-7 -- <br /> ---------- ----------------------- (Complete in Triplicate) <br /> ------------------------------------------------------ <br /> Date Issued_... -.`---- � <br /> ed <br /> This Permit Expires 1 Year Z. 1 1 Date Issu <br /> n is hereby made to the San Joaquin Local Health District for a e .l <br /> �A, <br /> Applicatio Y <br /> q - permit tocoand install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 aryd_existing Rules and Regu lotions-. T f <br /> �. - - - <br /> ----- ---- �-- - -- --E --------- CENSUS TRAC <br /> JOB ADDRESS/LOCAT0 �---/ m --/v. �,�,?,-', <br /> � <br /> Phoney "_ <br /> ------------- <br /> --- ------------ ------ <br /> "_ �j <br /> Owner's Name y ------- - <br /> C.t Zip-- <br /> ---------- <br /> ip <br /> -----------.fir------------------- ------ ----- on <br /> Address ----- ( 3 �-� _ ` <br /> . - _ �..--- �---- ------ -License <br /> n <br /> i" <br /> Contractor's Nam ----- -- .. ---�� ' <br /> Installation will serve: Residence ❑ Apartment House- A-1-le <br /> mercial Trailer Court ❑ <br /> r . : ._ <br /> Motel Other_- = �, { <br /> !/ �-�+<eG--------------- <br /> 4 <br /> Number of living units:--------"------Number of bedrooms.. ------ --Garbage Gnd� Lot Size----- --- {{ private <br /> PubliSystem�and"name_ -- -------- <br /> c <br /> ---:---- - <br /> 4 <br /> k Water Supply: t ' Peat -'Sandy Loam ❑ Clay Loamh�✓ ` <br /> Silt Clay ❑ ❑. -, ,. .3 <br /> Character of soil.to a depth of 3 feet: ; Sand ❑ ❑ O <br /> i Hardpan❑ . Adobe[I i Fill Material------ ----If Yes, type---E--------- --- -------------- <br /> showin size+of lot, location of system in relation to=wells: buildingsefic must be placed on reveal se.side:J ` <br /> (Plot plan, g = <br /> o e it ermitted-iT'pu6l;ic seyyerlis avar]able within 200�eet,) <br /> NEW INSTALLATION: (I�loeptic tank °„ r seep J--p p� <br /> Ts � Liq mid Depth <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] � Size.-__�"�-'-`�----- ------ ----- ,, <br /> ,.. ---- ----- ------=-- <br /> Capacity�' �` "=Type Foundat.lon _-� I <br /> aterrat . .. <br /> I - Pro . Line . <br /> Distance,to nearest: Well_ -- �, y Tat 1 r`. -�- f <br /> y t _ e <br /> LEACHING LINE., [ ] Na. -------------- <br /> ,6f Lines -" :-- ;-- ,-' --: - Length of,.each_line_ `_ f <br /> De th Filter Material k <br /> D Box------------Type Filter Material----------` p ..�., . �.- .x <br /> j <br /> s - _Pro ert Line)------------------ <br /> ! " p Y <br /> Distance to nearest: Well...__...- Foundation ___-"__ <br /> f+_ ------ <br /> Number; <br /> -`f ---- = Roc_.Fi d-Yes ❑ 1 'o <br /> k Iled Y s N <br /> SEEPAGE PIT [ l Depth---------- -- Diameter M it �. ._ _4 'VJ. <br /> 1 / Water Table be th-- `= .'---- -.RQck Size.. - <br /> p , 1_i w � , <br /> v1, _�� _._ -. ._ --- -- <br /> '/Disfance;to nearest: Well --------------------'--- -------- ------Foundation - .'Prop. Line:, = <br /> / f l # <br /> 1 - ,_....� ----------Date ----------------- <br /> -- --- ---- --- ----:-- ------ �---- --] <br /> REPAIR/ADDITION (Prey;So nitation•Permit# --- - <br /> .. . <br /> .I . �""" `.=` - --------------------------------------------------- <br /> Septic Tank (Specif.y.Requirements)"- --- -.-- �-- _��.:o= .�_ .. � �; ( La > <br /> Disposal Field {Specify Requirements - <br /> ---- -------- ------- - ----- <br /> -- ---- -- - ------- ------ =--------- ---------------------------- <br /> (Draw existing and required addition on reverse side) <br /> with San <br /> nce <br /> I hereby certify that I have{prepared this,applicatianoftthe ISon loaquinhat the work �Lo a Health Distrcd Home ownerr or,lic licensed agenoaquin ts <br /> i Ordinances, State taws, and Rules and Regulations <br /> i signature certifies the following: {"f1. d <br /> "1 Certify that in the perfo Imance of the work for which this permit is issued; ,,i II not employ any pars,(n .such manner as <br /> to become subject to Workman's Compensation laws .of California."." <br /> di Owner <br /> = - <br /> aA <br /> Signe ------- -- P <br /> ------- <br /> --- itle-- .. <br /> (If other than owner) �. <br /> FOR EPARTMENT USE-ONL --------------- <br /> Y <br /> ' s - .. t <br /> APPLICATION ACCEPTED B -----------=---- <br /> -- ------------- <br /> --------- ---' = DATE._�._� . <br /> .. .._. ._ �. .-_DATE =----,--�---� -- --- -- <br /> OF LAND NUM13ER------ -------- ------------ ------------------------------------ 'r`- ------ <br /> ti/ <br /> ADDITIONAL COMMENTS------------------ ---------------------- � <br /> -------- ------- <br /> ----- <br /> --------- ---------- <br /> ----- ----------------------- <br /> - <br /> -----Date- A <br /> Final Inspection by:---" & <br /> F85 21677 REV, 7/76 3] <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />