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06/06/2006 15:20 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) <br /> Permit No...79.-5Gp <br /> ...................... .._..................... <br /> . <br /> ...-.................................................... This Permit Expires 1 Year From Date Issued Dote Issued-.61q/.-7.4. <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 with County Ordinance No.549 and exissttting Rules and Regulations: <br /> JOB ADDRESS/LOCATI �fj [. - .......4 - .t1.....•.....--• .....CENSUS TRACT...........:............... <br /> ......Owner's Nome....-. - ---------A-- Phone...........................•-•_..... <br /> Address_..... �VVV-��• ..-..-. lJ'r eaa l/r� UL.cl <br /> r / 4 -.1..A.�------License #... a-.........--Zip.-_ +r- a..� - <br /> Contractor's Name..- - Z,. . .......Phone................................... <br /> Installation will serve: ResidenceEl Apartment House r,J" Commie p Troller Court [] <br /> Motel [] Other-7-P60-i .?._.,L .-p%-4_ <br /> Number of living units:.....I......-Number of bedrooms...,,r' ...-Garbage Grinder-.........,,Lot Size........3.0.4... - rL ^A.................. <br /> Water Supply, Public System and name-.................... _..............................-..-...... ----_------------------------------.............._........_Private <br /> Character of soil to a depth of 3 feet: Sand (] Slit❑ Clay❑ Peat❑ Sandy Loom ❑ Clay Loam [] <br /> Hardpan Z 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 I I' ' SEPTIC TANK (e Size.�if�a.."•.nI• .A_57.. ...-...... _Liquid Depth.--.. -.'..............a <br /> Capocty,I6e.!�----,-.Type:_. rMaterial--....Gsn.es':r---__No. Compartments......... ............... <br /> Distance to nearest: Well......_..-...-So,, Foundation.-___.141'._..-._..-.-.Prop. Una....... <br /> LEACHING LINE / r <br /> (IIJ No. of Lines------------3--------------Lsngth .Ak .. <br /> of eanch line...._. p ..............Total Length.......j_;ZL7-:,:................. <br /> D Box__!......Type Filter Material....-Sr..Aci�-....Depth Filter Material........L g................................................ <br /> Distar oto crest:Well.......,fi:a:�__.__.•.._,Foundation-.--.----I-D.-�.._.._--.-.Property Line....... <br /> SEEPAGE %T ( Depth................Diameter. .. ............Number........ ...__..__.__..__.__.. / b Rock Filled Yes No <br /> Water Table Depth_"-------/.fLRQ.-._.........t..--..............Rock Siu.._..... . ......i / <br /> Distance to nearest: Well.....-.-.-.PAP..1..................Foundation....1.k...............Prop. Line__4. ........_- <br /> REPAIR/ADDITION (Prev. Sanitation PermitflE.................................................Date..................._.........................) <br /> SepticTank (Specify Requirements)----------------- ..........._.....,........,.._..,..-.._-......--------------------------..............--•-----..•-----..-_.....-....----.-...-------- <br /> Disposal Field (Specify Requirements)-------------------- ........................................................................•---..-.......-.........__........ ......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 done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Load Health District. Home owner or licensed agents <br /> signature certifies the following; <br /> "1 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 /> to become subject to Workman's Compensation laws of California." <br /> Signed.;................................. .. ........ ....... -/-,Q (JIn---- ----.......--Owner <br /> .."'........................... ..... F�/�!11�rC._."�.A[.._ Title.... r r-------------------------­-- <br /> By <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY............... - ----------- DATE ............ ..... <br /> DIVISION OF LAND NUMBER........................ .................DATE..................._-....-.-..--------- <br /> ADDITIONALCOMMENTS..............................................,..------- .......:..........._--............---_.........-•-...........--............ <br /> ................................- -------...............................................................-.-_............................................... ----- .......... <br /> -- <br /> Final Ins byr..---_-• ..:. Dare.-. .... .......:...... .............. <br /> .'...... ... . ... .. .. <br /> EN n 2A SAN J UIN LOCAL HEALTH DISTRICT rAs zmn ssv,�p6 3u <br />