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FOR OFFICE USE: FOR OFFICE USE: <br /> PPLICATION FOR SANITATION PERMIT <br /> ........................................... ..----- -- e"' �.rPermit No9 -5.5 7 <br /> (Complete in Triplicate) ...~/.............. <br /> ............ -------------------------------------------- Date <br /> Issued,G.'.?.....-'79 <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 withCountyOrdinance No. 549 and existing Rules and Regulations; <br /> JOB ADDRESS/LOCATION.-�.S/y....::�CLlL1t° --- G'/-------- - .--A/.YIJL/.L..ytl-+CENSUS TRACT------------------------------ <br /> Owner's Name. ..._1 $ - ......... -- - - .Phone 7 - <br /> Address...--- .................. Ci,y._. ar� . Zip-- <br /> .. . <br /> Contractor's Name,4,.AAp...../7ell&A-..-------............-____..........._.License #a7 4-,3Z_PhoneX-,?-- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> otel ❑ Other-------------- ---_--------_-----_ / <br /> Number of living units:.... ---------Number of bedrooms-. . Garbage Grinder -.-Lot Size--1,70. - ..7d- ... . . .--- <br /> Water Supply: Public System and name---___.C!- - -- ....kial'-/, ...._--------------------------...------. - ----------------------------..Private El <br /> Character of soil to a depth of 3 feet: Sand C) alt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loom ❑ <br /> Hardpan ❑ Adobe x Fill Material . .... .._If yes, type........................... pi <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 [ ] Size....A. Liquid Depth.----------............... <br /> Capacity AR--__---Type�L�61...-.Material-.�C�,°�No. Compartments ---L---./.....--._---- <br /> Distance to nearest: Well`�6�.t.G 0AT44W--Fouridotion---./Q .'f------ ---Prop. Line...S.- -----------' <br /> LEACHING LINE [ ] No. of Lines t <br /> �...-_......__-_LengTh of each line Length __-��Q--�--._-----...-. <br /> D' Box.. .-._-.Type Filter Mat�e/riae`- eC CAR-Filter Material...-.-.. 7..t/-. - --.------ <br /> Distanceto nearest: Wei ,Gsd.1+-/V/fTitiU- oundation--:---- Q-1 ---- -Property Line.....,.r�..�-............... <br /> SEEPAGE PIT [ ] DepTh.I'l r-'...Diamete"r-. Rock Filled Yes No❑ El.3k3 -.._Number - -... . <br /> . <br /> Water Table Depth-------�Q- _ <br /> .... ...-.....-,.._-. .... .........Rock <br /> � 1 <br /> Distance to nearest: Well. 61t.�-K/i1R0&Zo---.Foundation.--/D�� ...._ Prop. Line...S-.<.'..-- -- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ---------------Date................----------.---- --- ----------] <br /> Septic Tank (Specify Requirements)_.-- --------- ------- .................................................. .... --------------- __...... --------- <br /> Disposal Field (Specify Requirements).--.................. ....-------------........._.-_-_----`----------------------.........--..--------- ----..- - --.._.-. <br /> ---................._.. .....------------- .........------.....----------------------------....-_......_.....--.........-------------------------------------..-..-----------..........---------- <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 local Health District, Home owner or licensed agents <br /> signature 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 /> to become subject to s Com r tion la s of California." <br /> Signed--7-�_ . . . -- ...... -- - -..-.Owner <br /> By-- -- - ......._.Title..-.t�GN��AC.-/cGt-....._.... <br /> ........ . . ............ <br /> (If other than owner) <br /> FO DEPART EN USE ONLY <br /> APPLICATION ACCEPTED BY...-- .. . .... _... . ..-. -- 7- .- --- -- - ---- - - <br /> DIVISION OF LAND NUMBER... ....--. ------DATE.--...------------- ------- .----- <br /> ADDITIONAL COMMENTS.- _...-...._..................... <br /> --------------------I-------------------- ---...._..- ------ <br /> M ......... .. . ................................ <br /> c tl . .......... <br /> ------------- --.-..._. ..... -..... . --- <br /> -- ... . ... ------ --- .. . ..... . --- ............... .......... <br /> - .Date...-..-----1 <br /> Final Inspection - -- -- ---- - ......... .... . - . _....._....._... <br /> EH 13 24 SAN JO/ IN LOCAL HEALTH DISTRICT as 21677 REV. 7/76 3M <br />