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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ♦., <br /> ............ <br /> '.... ....... ......_--.---- ------------ _ <br /> (Complete in Triplicate) Permit No.77_"S_)L"7 <br /> ( Date Issued.- <br /> `-------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 4pplication is hereby made To the San Joaquin Local Health Districtfor a permit to construct and install the work herein described. <br /> his application is made in compliance with County Ordinance O'0�54'9.and eeexxisttiing Rules and Regulations: <br /> JOB ADDRESS/LOCAnTIQN S__ tt7yy.._G �7 ".[/t "KG±f_-"_-�~.,,�ENSUS TRACT-l_4::I.�r------_M------- <br /> Tvner's Name.- G ._ 1- -� ------------.- - . ----------- ---------- <br /> -Phone_QJO L�- -.. <br /> rAddress.!"Z"7 � - City-- Q ---- ---------Zi . <br /> ` J P <br /> Contractor's Name-.:: JQ _------ �L - --11� �lCrNS. /. -license #_----�-..-------_-Phone-_"�"L= <br /> .nstallation will serve: Residence, Al5artment House [] Cdinmeriipl ❑ Trailer Court ❑ <br /> Olgkl�_.- <br /> Vumber of living units:_-1 Number of bedro�.._� .-Gauge Grgoder- NQ_Lot Size -"--"- -Motel" Other-_- _ <br /> Mater Supply: Public System and name------ -' - ----- --------- -- ------------ '- .-' -"------------------- <br /> Character <br /> --- -Character of soil to a depth of 3 feet: Sand Silt p Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Q: Fill Material ...If yes,type--- ------- ------- i <br /> t <br /> r � � <br /> (Plot plan, showing size of tot,Jocation-eff system in relation to wells, buildings, etc. must be <br /> D TANK <br /> , . pl¢�cecLdnirese3eVide.) <br /> AoP r seepagee pit permitted if publics within 200 feet, <br /> r A AGE TREATMENT SEPTIC TANK [ Size .Ilguid Dept[L _ =`; <br /> z <br /> - <br /> Capacity"-_1-Z(0_ --t-Type _L,* ANateria (� <br /> 4XG7C F No Cdrtf artmeh s'^ ? __. J <br /> Distance To neare5taWell �/`.�� -- data 7 Totallteng}hrop. Line----. <br /> it <br /> LEACHING LINE [ ] No. of Lines-. Len th of each lin P 7-- - <br /> }' - .. _ e th Filter Material . . / <br /> __- Distance to nearest: Well ��,�N_F tion. � p /� - -- - -- <br /> -- <br /> I Type Filter Material/` - <br /> WI�S > ---- --. �f --- - - roperty Line_ 1�0� <br /> >t <br /> " [ ] Depth-10St - Qiametery-----�-.----Number-_------ ----_---------- -- Rock Filled- i;yesA No <br /> Water Table DepthSi!'f7a --------- - ------.Rock Size-----/—� /��- =- <br /> �'-- --- <br /> r / <br /> Distance to nearest: Well--.--- ."�� --- -_ -------- "----_Foundation._ _ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------------------------------_Date___ --------------- __-) <br /> `ieptic Tank (Specify Requirements)_---------- ------- --- -----------M_------------------------------------- ------- ----------------- ------------- ----- — ' —� <br /> Disposal Field (Specify Requirements)-----'--------- ------__""----------'------------- <br /> *'- ------------------------------- <br /> - --------------__. <br /> ----'------'-- ------------------------------------ <br /> -----------. ------------------------".... ----------------- '--- -------------------_.......-_--""""-"---""-------------_-----------------------------..."'------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun <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 performan of The work for which this permit is issued, I shall not employ any person in such manner as <br /> 10 become sgbr to I rk n'i Co n <br /> eation laws of California." <br /> Signed --- -- - ---------------Owner A <br /> By------ ----_---------------M.......... '------' ........ ---------- - ---.Title.--------- --------- - ----- ------ -- <br /> (If other than owner) <br /> R DEPARTMENT USE ONLY <br /> rAPPLICATION ACCEPTED BY -- _ '-- "-- ----------------------- -------- -- ------ DATE. f9 _ Z <br /> -------- <br /> ---- -- <br /> DIVISION OF LAND NUMBER --- --- ----------------------- -------------------___-----------------------------------------DATE------- ------------ -------- ' ----- <br /> ADDITIONALCOMMENTS----------- - ...................M-------"'--"--------.._ ...... _....... ... '--"..... '------'.--------...--.-."------- ------------- ------ <br /> - <br /> -------'--------------------------------'------------- <br /> r <br /> -----------------._.._---_--.-_-------------_--_.__ __. .-- -- <br /> ..-- _--- ._ <br /> _"-- _-.-----_-..............M--------------..-.--..--__ <br /> Final Inspection by:---'- '-"'-'--' - ` "`' ------ -­------------ -'-' ' ------Date---- �-----------M------------ <br /> � ----------------. <br /> Lel 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Fb5 21677 REV.7176 3M <br />