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FOR OFFICE USE: r( FOR OFFICE USE: <br /> lPPLICATION FOR SANITATION PERMIT `,( <br /> (Complete in Triplicate) Permit No;7e_,?6,3.. <br /> - - ------ -------------- <br /> Date <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 /> 20& 01 <br /> d <br /> JOB ADDRESS/LOCATION __-..pp/04".-._. - OAC .44e --- 5{.---- sCENSUS TRACT--------------_--------....... <br /> Owner's Name 4,p.._S2�O'-t.(:-- __Q - -- ----- • ----------------�p�-.---,--n-.y �pP,h�.o..ne..?X/�es,�..7_i1Y-_1_,a <br /> Address.- . -------- �'-( - -s-c ------------------- - -_Cltyvf�lM1#..Z&;e �ZlC' _Z1 ---------------------------- <br /> O P <br /> Contractor's Name-----------L..._ ... -.---_ --- ---s ---------------------License 4-L� .Y_3.---Phone._3X6� -_.YI-&7.. <br /> Installation will serve: Residence Apartment House ❑ Commercial Trailer Court ❑ <br /> Motel ❑ Other..___ p _ - a _ <br /> Number of living units:....._.....__-Number of bedrooms.__-___.Garbage Grinder_ ---_----Lot Size......----Y J_...-....._.____._... <br /> Water Supply: Public System and name---------------------------------------------------------------------- -----------------Private X <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe"X 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,) �� O <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [�Q � 'ze.._ X... ._ __'.__._------------------Liquid Depth. ------------ <br /> --/" .O <br /> Capacity..� �._....Type- "`c�------Malarial--`^ W ----No. Compartments--------- rZ-------------- <br /> Distance to nearest: Well__---/_�..._'f..._..___.__.-_.._Foundation..._____._..._...Prop. Line..d.____....._____.. <br /> LEACHING LINE No. of Lines_....__..---..- .Length of each line_---Cy.S_r----__ -------Total Length ---------- <br /> �` ���� sy <br /> 'D' Box._._V.Type Filter Material:. FQp- ...t�Depth Filter Material_____ g...._--------._-------------Z_.._..._-_.__.... <br /> Distance to nearest: Wei l-----f60_�__-Foundation__�Q..."f.....__Property Line-_._�.__._-._.............. <br /> SEEPAGE PIT [ Depth...44* .-Diameter ._Number.............._2 ___ Rock Filled Yes No o <br /> 3 it <br /> Water Table Depth---------------------- --------------------------------Rock Size--- �- k - - --------------- � <br /> Distance to nedresY: Wel(,.__Lt4G._'t"-------------------Foundation_ _l.@__+'.__..Prop. Line... ...._....__-_._.... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....................._._� .__.__._.....Datio ) <br /> �} --------- ---.---------- <br /> Septic Tank (Specify Requirements)- - -------- ..._ -- ------------- -----^p - <br /> Disposal Field (Specify Requirements)---------- -- ------- ----- --------- ---�---- --- <br /> - --------- <br /> --- - -- - -- - <br /> --- --- --- - - - -- <br /> (Draw existing and required addition on re rse side) <br /> 1 hereby certify that I 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 Workman's Compensation laws of California." <br /> Signed /�, Owner <br /> By---- --A '�/ Title . - - - ...- <br /> Cher than owner) <br /> D ARTM T USE LY <br /> APPLICATION ACCEPTED BY-------- - ---------------------------DATE. L- - - <br /> DIVISION OF LAND NUMBER.-- -- --- ----------------------- DATE - ---------- <br /> ADDITIONAL <br /> -------- - - -- - - <br /> ADDITIONAL COMMENTS.._....--------- -------------- -----/-----------------_ ----------- --------------- ------- <br /> ----------- <br /> ---------- - - <br /> ---------SL7 1r38._- <br /> - -- l Inspection <br /> -- do <br /> ----------- <br /> ---------- -- <br /> - -- ----- <br /> Final <br /> - - <br /> Flnal Inspection by:--------------------------------- - -- - - -- -- - -- -- ----- - - - - Date------ - - - - ------- <br /> EN <br /> — <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F63 21677 REV. 7/76 3M <br />