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`OR OFFICE USE: VFOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMM/ <br /> .......... <br /> ... -- -................. ---------- . Permit No. <br /> (Complete in Triplicate) 772 c��3 <br /> .. <br /> ................................................... ---- Date Issued...I( 7 <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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION-. .CENSUS TRACT- ---------------------------_ <br /> /- t� p A <br /> Owner's Name._--.G F-------...�L!/✓--.iG-G' t'..-K-'_I✓� ------------------------------ -- --- y -....Phone.... 6 <br /> ✓L"L 5�(i�-/2... " <br /> Address.....................S-��` �--------------.--------------- ------.-_---------- -------------------------zip-------------------..... <br /> Contractor's Name.----------- -/.. r.-Fv L.L"i�..t�---. --------------------_ ----License # -? s' - .,_..Phon;P. _7/.. <br /> Installation,will serve: Residence V �.�Apcirtment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ .,--Other TT ------------------ - ----- ------ <br /> Number of living units:-_l_:_-...Number of bedrooms 1`'._Garbage Grinder__--------Lot Size._!f¢.-vii .--..--- __- <br /> Water Supply: Public System and name----- ------------------ ------- ---------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay g Peat❑ Sandy Loqrh ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material -if yes,type._-...._.-61 <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on revwse'side.) <br /> NEW INSTALLATION: [No septic tank or seepage pit permitted if public sewer is avadable within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I 1 Size---.-._.. -------------_-_____----------------------Liquid Depth <br /> Capacity---------------------Type---- ------ ----------Material- -----------------. --No. Compartments.------- -...-.... .A---xi <br /> Distance to nearest: Well----------__..- ---------.-------------Foundation------------ -------------Prop. Line--------___...------ ,W <br /> 0 <br /> LEACHING LINE [ 1 No. of Lines.---------------------------Length of each line_ ------------_----_- ------.Total Length --------------------------------------- 0 <br /> 'D' Box........__Type Filter Material_ ----- Filter Material._-.-_-.-_-.-_.___--- .-'._---------------_..--- <br /> Distance to nearest: Well----------------_-.-.--._-Foundation._._._...._-------------Property Line......._................__...... <br /> , " <br /> SEEPAGE <br /> T [ ] Depth.....____---Diameter_ ..........-......Number- Rock Filled Yes,❑ No,❑ <br /> Water Table Depth--.-----..------------_- _ ------------------------Rock Size-- ---------------------- <br /> Distance to nearest: Well - ------ ..Foundation.,- .. p. <br /> Pro Line...... _...� <br /> REPAIR/ADDITION.(BrS --------_ <br /> ev. anitation Permit# -.-. -- .. .--.Date L <br /> Septic Tankt(Specify'Requiremenis) .--. .1 ---. ----� � - - -I- - - -- <br /> Disposal Field (SpecifyRequiremenis)-- -4Et.. .c --------------- <br /> --­------------ <br /> -- -. ....-. --- ---- <br /> _ t <br /> JDra„4x g and'reulred additlonjoriteverse side) - P <br /> 1 hereby certify that-I have prepared this'npplicatf�n and that the work will be done in accordance with San Joaquin Court <br /> Ordinances, State- Lows; and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agen.4 <br /> signature.certifiesthe following: - <br /> "I certify that inthe performance' <br /> of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Wor mannIss Compensation laws' of. California." <br /> Signed y� �.LG'.:. <br /> .- ..... .iG. -- Owner <br /> By........ - - - - .Title - _ _ <br /> ........ <br /> (If other than owner) (( <br /> R DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_........ . -}-- ---------------- -------------------------- - DATE.` - .. .. <br /> DIVISION OF LAND NUMBER ---- - ...- 7 :-�- ------- _ ---, DATE ----- ;. ---- ------------ <br /> ADDITIONAL <br /> -------ADDITIONAL COMMENTS---------------------------------- .......... ... . - ---....... ..... ........_. ---. ------- ------- .._............. <br /> ------------------------------------------------------ -:------- ------------ ----------.--- --- - ------- - ----------------- _-------------•------- <br /> .......... -- - - -- <br /> r <br /> ---------------------------------------- ---------------------.------- ----------------------- ---- --- <br /> Final Inspection by:------------ qi" - - --- ----------- .-..-.. - -----------Date._ <br /> Er113 24 • SAN JOAQUIN LOCAL HEALTH DISTRICT F6621677 REV.71763M <br />