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FOR OFFICE USE: .�' FOR OFFICE USE: [ <br /> APPLICATION FOR,,SANITATION PERMIT <br /> k <br /> !l <br /> Permit No.. ..y . •�• <br /> ' " (Complete in Triplicate) <br /> Date issueci..3:nS-7,f <br /> This Permit Expires 1 Year From D <br /> s afe Issued i <br /> Application is hereby made to.the San Joaquin Local Health District for a perm it to construct and install the work herein described. <br /> This application is made in compliance with County Ordina_{nccee.No. 549 and existing Rules.and Regulations:. <br /> JOB ADDRESS/LOCATION___ �8.._.C�O�Q. .. = K. ------- --•--.CENSUS TRACT_ ..... <br /> Owner's Name �.D_.. '-1 t" �7 -r .......... ........ ... .. <br /> �i ��._. <br /> / L �� f'uDI�E--- --.- ZIP -g . . _. <br /> Address--.- -- I� /oZ. _. b_� .Q.....� ... ----- ...... ....... City_._ . .. <br /> �S� <br /> Contractor's Name-- -- �L/�S�}.... d ,S..-----... . <br /> License #-tS � 3• `'� Phone_... .'_. <br /> ion will serve:.• Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Installation i <br /> I Motel ❑ Oer. <br /> �th �.�t <br /> ._..._.: <br /> 7`::. Gorbba e Grinder__._..------Lot Size.---.--- -----��x:�.--- <br /> Number of ._.__. . <br /> living'oni'ts::.. - _._. 'Number af'bedrooms.. ._.. - <br /> ,� g <br /> `�. <br /> .................Private ❑ <br /> '----_� . .._._. <br /> Water Supply: Public System and name.._...... ... ...... <br /> Peat Sand Loam ❑ Y ❑ <br /> ' Clay Loam ' <br /> Character of soil to a depth of 3 feet: r Sand ❑�,Silt ❑ Clay ❑ Y J <br /> Ilardparx Q AdobFill Material.. ..-- -..Jf yes, type..- <br /> . <br /> COO <br /> (Plot plan, showing size of lot, lobation of cyst rn n relation to wells, buildings, etc- must be placed on reverse side,) <br /> NEW INSTALLATION: <br /> /(No septic tank or seepage pit permitted if public sewer is available within 200,feet,[ <br /> �! <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] <br /> Size.. ------.. "--- •------..__Liquid Depth.- ---r,, <br /> CapacitYry -- '_.... ----TYpe------- ---......-:.:.Materia ------�I--'-�----- -�-�--•--::No:Compartments ------- •------- ----'---' -----•- ' <br /> " undation._.----'.-- ------Prop, Line---------- <br /> Distance'to nearest: Well------ ------------- Fo <br /> �ITota! Length .......-._:--------- <br /> LEAC!PING LINE E 1 No. of Lines. - ---------- --------- Length of each ling -----i ----------------------- <br /> 'D' BOX' -Type Filter Material........ ..... ....'Depth 'Filter Materia ----- <br /> --_.... <br /> II� ......Property Line <br /> -------------- <br /> 1Qisfiancato nearest: Well_.'--.�.--------- .----- Foundation--ti:: -*,A <br /> p Y <br /> ,f ` SII Rock Filled Yes ❑ No ❑ <br /> SEEPAGE PIT [ ) Depth.- ;----'-1' .Diameter- --------- --------Number <br /> i r: i <br /> Water Tdble Depth <br /> Depth-----,.-.-.-�------ = .•---:_i _.Rock Size--.----- -" ... <br /> -----.Pro�p...L.:i.n <br /> e.. -- <br /> Dateation.----- <br /> ' <br /> DiYtanc*e to nearest: Weil---.--- .--- - <br /> REPAIR/ADDITION (Prev. Sanitation Permit#' -. -- -•- - -- /4---- ` <br /> a-_ .-, t \ � J <br /> Septic Tank {Specify Requiremen : r --- / i �• <br /> =ra .------ ...... <br /> Disposal Field (Specify Requireme --= `] <br /> .................. . _..._.,..._.-.._.__...- <br /> I ........................... IL <br /> . . .. ---- -- -----------"---._... <br /> ------- ........ ..................... : ....... -...... -- <br /> -._.__...---'--..._..___.__----•-----•---.-------._....----....-..... <br /> {Draw existing and required addition ;on reverse side) <br /> I hereby certify that I have�preppaared 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: j I ,i '\ fi f <br /> hl <br /> "I certify that in the performance of the work for which this permit is issued, I shall not e+x>ploy any person in such manner as <br /> to become sub'ect to Workman's C pensatiori laws of�Gafornia."'"``z" <br /> Signed ----------- --- 4 -Clwner <br /> B _ '`f� G __.. - ----- Title ; S.% ' <br /> Y (I,f other than owner) A <br /> ' OR EPARTME 'USE ONLY' " <br /> .DATE <br /> APPLICATION ACCEPTED BY- .----.-- --- -- --- ----- <br /> ------ <br /> - � i `3 <br /> � - _ ::_.....----•�. ...... ......� ..DATE.._ ---...- -------....-- ----- .....-.. --- --- <br /> DIVISION OF LAND NUMBER.-- --...... -------------- ------ ... ------ <br /> �__ <br /> --•------------ •--------------------- <br /> ADDITIONAL COMMENTS.. _._.caN�--------._._.. C.�`1._...---...-�-- A. Il �-.._.. <br /> ----------------E ------ <br /> -------•-------------------- ------ .................-... ---- ------------------....--- ............ li - <br /> - ------ --------- - --- --•---• ------- ------..._....... <br /> --------------...-' I. Data 3 ' <br /> ------ ----- <br /> �Knal24nsp.ecttan by:..---- , --V_ cj�c�'.............. . it <br /> F&S 21677 REV. 7/76.3M <br /> 13 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />