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f FOR OFFICE USE: <br /> f FOR OFFICE USE: <br /> APP!(CATION FOR SANIl TION PERMIT pp <br /> Permit No....711..:a � <br /> ........................................................ (Complete in Tripu•tite) <br /> Date Issued... .......... <br /> This Permit Expires I Year From Date Issued ' <br /> 9 <br /> Y lica'ion is hereb made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> A <br /> This application is mode in compliance with County Ordinance No.549 and existing Rules and Re ulations: '. <br /> .�._ .. .. <br /> 12 ,,y .. <br /> 4Y <br /> JOB ADDRESS/LOCATION...... .... � .._�.� ........k .?l/��._.........�,.........................CENSUS TRACT...... <br /> ........................... .................. <br /> Phone <br /> ffc3 <br /> Owner's Name...._... .. f. ............................ . <br /> ... .�- <br /> Address........... '5 4.1!7 AF. ..........................City...`r�(?i9C Z'P <br /> ............. .... <br /> -- -- - <br /> -- Phone..... 6 . <br /> , u - i .............. •.--..... License #a-... - <br /> Contraitor's Name........ . t. <br /> Install ion wil s <br /> —Residence H Apartment House❑ Commercial ❑ TrailerCourt <br /> = N <br /> -• Motel ❑ Other............................................. <br /> Numb of living unIts:..:..-........Number of bedrooms- ..Garbage Grinder............Lo $iz ••-••••((..... ;5 <br /> . .. .............1.......................Pnva�� <br /> ❑ ❑...._..._ . ............❑ ...... 4l <br /> Water Supply: Public System and name.......................... . <br /> :�; Ohara er of soil to a depth of 3 feet: Sand Silt ClayPeat Sandy Loa{t Y Clay L am �' <br /> �/` <br /> Hardpan❑ Adobe❑ Fill Material............If yes,type........••••'�•• k•�••� t <br /> �Alof pl n, showing size of lot, location of system in relatio `\we""bu'ydings,etc.must,��g Rl ced on r v�r sid .1 (}� <br /> P \ <br /> _ NEW I STALLATIONs (No septic tank or seepage it tte if publi sewer is avaflab�within 2 0 feet,) i <br /> Siz Li d Depth........... <br /> ' PAC E TREATMENT ( ] <br /> SEPTIC TANK [ l "' 1" q P <br /> CapacityTyp 7i;—Material <br /> No. Cpr+i a. <br /> .. e.. <br /> } Distance to nearest:Well.....................r�U.��y ��.Fon........ <br /> C' a�)oop ne l. .. <br /> .... <br /> :. j .... <br /> j Tbtal Len�th_..._... -.�:. <br /> No. of Lines.....- en§ih of each line.................:.......... ✓� <br /> Type <br /> LEACHING LINE,. J-] �1 ; <br /> 1,Q, a erial....................Depth Filter terial....�............-�•- -........ . <br /> "' <br /> "V i <br /> D Box............. <br /> ' • Distance to nearest:W . oundation--_............... Prope Me...-. ..... <br /> *' �1`�......... <br /> ........ ... .F <br /> P <br /> ,. .. .. Nu bet................. .l R Lfbd Yes❑ No'❑ <br /> # <br /> SEEPAGE PIT [ 1 Depth................Di,z ete -..{_..-..... a <br /> ,. <br /> Water Table Depth. .. �.._. C..3� 1� L� ...i• �.....�f!.... � k <br /> ' ...... f <br /> ...Foundation.......... �........(P p: ineT. <br /> ` t s <br /> Distance to nearest:Well...... -�..1_ D to <br /> ,. <br /> REPAIR ADDITION (Prev.Sanitation Permit .................. <br /> (Specify Requirements) <br /> (Sp — <br /> Septic ank ec . .G�..... . <br /> .. ........... ......� . .. <br /> � i ...................•..1: <br /> Dispos I Field (Specify Requirementsl••• <br /> .................................Q-- ............ <br /> ....................... <br /> ........................... -.. .. <br /> ............ ............................ <br /> .......................... .......... <br /> ... .. ' <br /> (Draw existing and required addition on reverse side) <br /> Mreb certify that I have propared this app oma^ hat the-worlc'wlll-bff"d�ciffed ari' w an Joaquin County <br /> Ordinances, State Laws, and Rules and Rel ulations bf the San Joaquin Local Health District, HoTV <br /> a owner o licensed agents <br /> signotaa�ro certifies the following: d <br /> Ianon in such manner as `y <br /> "I cern that in the performance of the.wor for whicil this permit is issued, I shall not employ a p ,f <br /> to bec ms su iect t or an's Compens •on laws 'of California." <br /> Owner i <br /> Signed <br /> s <br /> ............................... <br /> .................. i e.. ..._...... <br /> (if other than owner) \ ' <br /> i. FOR.•DEPA MENT USE.ONLY 2` <br /> 1. —. <br /> .. DATE.-...... ....�...- ....... <br /> APPLITTION ACCEPTED B' �DATE..._............... .......................... ' <br /> DIVISI N OF LAND NUMB' . ................. .... -_ ____. .--............._...... ....._ •••-•_.__ <br /> ADDITIONAL COMMENTS............................................................................................................................................................. <br /> ........................................ # <br /> j ... <br /> ..................... . ................................................. a ... - <br /> !J........... . <br /> Final Inspection by:... � LOCAL HEALTH DISTRICT JOA <br /> FaS 21677 REV.7/76 2M <br /> SAN <br /> EK 13 24 <br /> 7 ...j... <br />