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................... .... ...... ............. APPLICATION FOR SANITATION PERMI rUK %A-t-A..0 UJc: <br /> ­ <br /> (Complete in Triplicate) Permit No....................... <br /> . This Permit Expires 1 Year From Date Issued 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 /> his application.-is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> O$ ADDRESSAOCATION...... :........._. X'l..C.�.............................. <br /> ................CENSUS TRACT_..._.....-- -- <br /> )wner's Name.... .... . ... `._: ........_0r�l!T................ Phone—/(O /S 1!Ci ..... 9�c� 3 <br /> ..-.�,°1 5f.�.-----. .r........... .... ..City 1p/► ....._...............Zip......_.'_.......... ..._.. <br /> :ontractor's Name..-........`" T l C?i.S _.�.Ir �•L2. _/f-�....... /S Phone.-.. <br /> ...........License #-`' . ......... ... <br /> istallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br />�I <br /> Motel ❑ Other................................ <br /> ..........._... <br /> Dumber of living units:......I........Number of bedrooms__.� ... .Garbage Grinder....: .....Lot Size........ . . .,. -,._. ...... .. <br /> .. .. <br /> Vater Supply: Public System and name.........................................................1­1 . ........Private [U <br /> :haracter of soil to a depth of 3 feet: Sand 0 Silt❑. Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan W Adobe ❑ Fill Material.. .... ....If yes, type............._ _............... <br /> 'lot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> IEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,j <br /> ACKAGE TREATMENT [ } SEPTIC TANK S .�l....f :�:Sx 9 ...._......_ y � <br /> [�'}' Liquid Depth.._.:- 'Zi <br /> Capacity_Al �� TYpe': .....'..... ........Mate,rial._ (.�......_...No. Compartments........:92............I.......� <br /> Distance to nearest: Well...._ ,5;2e ................ ..........Foundation_. .._ ...Prop. <br /> Line-.55,........... -� <br /> EACHING.LINE �-_•__.......... .-_ : <br /> Length of each line _��.... �......... h ... ._. <br /> Total Lengt . 12c? <br /> [� No. of Lines . ......_. .....................� <br /> .. a <br /> 'D' Box............Type Filter Material. _. ..h fl'..Depth.Filter Material--------- .............. <br /> Distance to nearest:"Weil... ................ ... <br /> ......Foundation._ _12V...............Property Line:.._.f ......... <br /> EEPAGE PIT [i}� Depth ......Diameter.----:13-........Number.-......sz?-. ................ rr Rock Filled Yes ` No ❑ <br /> rp a <br /> Water Table Depth...........0-6........................................Rock Size....Oq ------------------------ <br /> r <br /> i � 11 <br /> Distance to nearest: Well......... .Q......................Foundation..../ ........-.Prop. Line...... <br /> EPAIR/ADDITION (Prev. Sanitation Permit#................................... ... .. ........Date_•_..__.:_..._..._.__..._......._...___.-.._..) <br /> eptic Tank (Specify Requirements)................................ ..................................... <br /> )isposal Field (Specify Requirements)...................... ............. .---.--. <br /> ......................................................................................... --._......._....... ....... <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County <br /> trdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> ignature certifies the following: <br /> I certify that in the performance of the work for which this permit is-issued, I shall not employ any person in such manner as <br /> becom"biect to Workma ' Compensation laws of California." <br /> igned....;1 �-f <br /> ....... . ... . ... . ..... .... ....._..._-�..... ....-------Owner , <br /> 'y....... ...... . !� <br /> . �. C}ry ...... Title..........: .. ..r--._......_._......... <br /> ill: other than owner} <br /> OR DEP RTMENT USE ONLY <br /> kPP.LICATION ACCEPTED BY........... ...................•................_DATE .......- <br /> tIVISION OF LAND NUMBER................. .._............._.._....DATE....---......_........---...... ................ <br /> ADDITIONAL COMMENTS... ......................... .......... - ... .. ... ...... , <br /> .......................... ........................................ ............................................ ............................................................................ ..... ... ...... <br /> .. <br /> ............. .... . ....__..........................._................................--....._.................._....... .......... .. <br /> y:........1 <br /> ................................ .......... ... ....-..... <br /> inal lnspeciron b ' ..-•---...................._-......_..........__......__..._....._Date..... ._. _..... <br /> /76 7M <br /> i 13 24 CAAI InArtlilt\f rnrAr WPAITU niCTDrrT f6S 2167,7`fjrrP;7 <br />