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FOR OFFICE USE: -- " FOR OFFICE USE: <br /> s APPLICATION FOR SANITATION PERMI �{ <br /> .• j Permit No-..Ff-�-------:.-- <br /> ._..---•-••--•------._._...----�........... ............. (Complete in Triplicate) G- /� -7� <br /> . <br /> ............. •---...-----...--- Date Issued._........... <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 app.licotiort.•is made.in compliance with County Ordinance No. 549 and existing_Rules and Regulations: <br /> 11 S TRACT...... --- ........ <br /> JOB ADDRESS/LOCATION -- :��p -- �-� rl.G.h-- -----•------ ---FIL.E-C-o"_Owner's Name_..... �.. (i..----....0 P�Y�... __ ----------------- hone _ 7. ..... <br /> �: .... ------. <br /> Address....aZ..i0s.t-.6,.9AS'.�:&rk\....1+4e,t� .. :--.-.1�1�2�C ' :.- City � . _ <br /> Contractor's Name-------- ---_. .- <br /> J 4.io- .........License #_ �s.._3r-,..-Phone-- -- - ZG� ~ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other. ...................................... go <br /> Number of living units:...... --------Number of bedrooms-.3.......Garbage Grinder- :n-....Lot Size......... ..... <br /> Water Supply: Public System and name.... .......... ... ..._...:.................................. e_Pri ate . <br /> V <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt L] Clay ❑ Peat El. Sandy Loam [] Clay Loam El <br /> Hardpan W Adobe.❑ Fill Material.. .._. -...If yes, type----...................... <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or' seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) .: SEPTIC TANK [t-r <br /> Siie ._�1r -_S - Liquid Depth. -y------ <br /> Capacity.4 ------•TypeJPf-!"�`""i-.--Mate'rial-_ - ..:No. Compartments._..__:.:fl -.f:.----• --•-• <br /> '.. � <br /> Distance to nearest: Well...... •7_,. . ....... .........Foundation_ ' �.. _-::...... Prop. Line. . <br /> i--- <br /> . N . of Lines . _.. ...... ---- Total.Length ._ ----12. : •---.... <br /> LEACHING LINE -- Length of each line <br /> , <br /> D' BOX............Type Filter Matteeriia�l,5-/P-�/..Depth.Filter Material.'.'.. <br /> Foundation <br /> -- <br /> Distance to nearest: Well--- /' --�; Foundation.---- -�_..........Property Line_._ °` - <br /> - . ri <br /> 53.---.....Number........�................... �i f! Rock Filled Yes No[:) <br /> SEEPAGE-PIT [L�. Depth..r`.---......Diameter.._._ , <br /> ` Rock Size.... . --- -------- ----- •------- ' <br /> Water Table Depth.---:./CSL .. <br /> I oundation..:_ ` ...:....-.Pro line-----_ _. <br /> 1 Distance to nearest: Well----------- d-Q. ------- --- . �� p. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#________________:__--..--...----- <br /> -- ----------­-:Date .............. ---- --------- <br /> Septic Tank (Specify Requirements)---- --- --------•----- <br /> y <br /> Disposal Field (Specify Requirements)------- --------------�. ----------------- -------------------------•- <br /> (................. <br /> [ ... - - - :. ... <br /> -- - - ----- •----------- ------ ----•- •-----..... <br /> i --------------•-------- -- .-- ------------. ......------•--- <br /> ---- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and-that the work will be ddne in accordance wis '"San Joaquin County <br /> Ordinances, `State Laws,. and. Rules and Regulations of the San Joaquin Local Health District, Homeowner or licensed agents <br /> signature certifies the following: ` <br /> "I certify that in the performance of the work for which this pmermit is;�issued, i shalt not employ any person in such?manner as <br /> to becom b[ect to //Workma Compensatiipn laws of California." <br /> Signed.. ` 1l - -•------.-- �.._. Owner... i <br /> aF�J=,r --- -- --- <br /> i i ....... Title..--•-- <br /> By... ..........:. . •--- ..: r- . <br /> [lf other than owner) <br /> OR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------.. <br /> .----...DATE -- - ------? <br /> .... <br /> ------ DATE----_---------------- -------- .........._.:... <br /> DIVISION OF LAND NUMBER............... <br /> ADDITIONAL COMMENTS-------------------- -.---.------•---------.-. ------------:----•----- <br /> . ----_:.. ------• -•----- - -----••--- <br /> �$ <br /> k <br /> - , ..--- afie-- <br /> Fina! Inspection by __.._- . F65 2167)jWri7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />