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Permit N <br /> FOR OFFICE USE <br /> ..-..._.. . -••-•---------•-•--•--- :............I FOR OFFICE,USE: <br /> APPLICATION FOR SANITATION PERMIT PermQ 6 <br /> �II o.--��-. <br /> (Complete in Triplicate) �• <br /> -•• <br /> -------- ----............. ------•---•-•• . <br /> Date <br /> .............. . This Permit Expires 1 Year From Date Issued <br /> )plication is hereby made to t Ie San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> is application s made in com oliance with County Ordinance No. 549 and existing Rules and Regulations: M _ <br /> iOB ADDRESSAOCATI :.7. Q- - `:.----.---.CENSUS TRACT------------ ----------------- <br /> wner's Name........:. ...: .. ! L - --------- --- -- ---------- hone.__e� 4 • <br /> Address---•••:............. . . •Q'- .- �.�'g....----•- ..... City .._: - ZiCp <br /> . . . '. G7 .............. .......License #_ Stf_'._ Phone.. <br /> ontractor's Name__________ __.__ . _ -_. <br /> .:,stallation wiil-serve: Residence Apartment House.❑ Commercial ❑ ;Trailer Court ❑ <br /> _.. . / ;__,.� Motel ❑ <br /> -Other-----•----------------_----.. -----` <br /> umber.of living units:__...1.....__,_Number of bedrooms:._�e%".�_...Garbage Grinder_._-._..._-Aot Size._j9_ ____ .._•2 �-7 <br /> - -- -•--- ------------------------ --- <br /> Water Supply: Public System and name•--' _.. - Private <br /> - --- -- <br /> -' oracter of soil to a depth of 3 `feet: , Sand El -silt Ll .Clay❑ Peat❑ Sandy Loom E] -Clay Loom ❑ _ <br /> Hordpal'❑` Adobe: ' Material----------..If yes,type................................ <br /> (Plot plbn, showing size of lot, location of system in relation to:wells, buildings, etc. must beplaced on reverse side.) <br /> 6V INSTALLATION: (No-septic tank or seepage pit perrr'tfed if'public sewer is available within 200 feet,) <br /> rACKAGE TREATMENT i ] <br /> SEPTIC Q Size..__.r�...)<_. :.".. ............::....:".____Liquid Depth.__ _--._._.___.__� <br /> i Capacity.�S�. _.-.__Type._l + .-____Material_ ' -�._..._No. Compartments.-___72.....................CA <br /> �� O� / 7!7..---- - ----------- <br /> r J <br /> ( . Distance�to_nearest: Well.__..1__________________________________Foundation----/0.,.__ ._.Prop. Line-__S_... <br /> LEACHING LINE::• [ No. of� me's__---___.:_Z''-----------Length of each line-------- ...........Total Length._____�_TO--_._................f__ <br /> D' Bo��.....____._ ype Filter Material-__1 --Depth Filter Material_________ZC?_"._`-•-_.___-___-•__---.___................ <br /> . . - . . . . <br /> Distancetonearest: Wel l_:---l' _-�t__......Foundation_..:_f0_f2`'____:_ Property Line.......`_.'_.._-------------- <br /> SEEPAGE PIT :QQ _i ..4._..__Diameter_ ------ ol ❑ <br /> Water Table beptT, <br /> h.------------_--- --------- ----•-_.._.Rock Size.- -�- ......•... <br /> Distan �e to nedresf:Well- 1, _0_......._-.___...:....._Foundation._.___ ':..'_•.`_.Prop. Line_-5.:..----- <br /> .._.._.j__. <br /> EPAIR/ADDITION (Prev-. Sariitdl`tion Permit -".-' <br /> ...... -.----. _------._._..:....------....} <br /> sptic Tank (Specify.Requirements),.....,.,..�._:.........................:-----• = .. - _ <br /> Disposal Field (Specify Requireents)---------------------- -- <br /> ........................... -•--------- -_...................................... .................. ----- -------------------- <br /> ----•-------------------•. - •---------------•---•- <br /> r -- --------------- ---- <br /> (Draw existing chid required addition on reverse side] <br /> hereby certify that'I -have prepared this application and that the work will-be-done in accordance with San Joaquin County <br /> urdinances,, State Laws, andRules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following� r <br /> cerfify that in the performa'iice of the work for which this permit is'•issued,-I shall not employ any person in such manner as <br /> Td become subject.to Workman`s Compensation: laws of California." <br /> I <br /> cigned - Owner = . _ <br /> s <br /> Title________ _______ <br /> f other*than owner) <br /> FOR DEPARTMENT USE ONLY t <br /> APPLICATION ACCEPTED BY... ------------ ...........-- ..................................................DATE..:.._ <br /> DIVISION OF LAND NUMBER _- ----- --------•------'- ----••-...•. -------••-•------ ............_•••. ....... DATE ................................... <br /> =ITICNJAL COMMENTS--------*. ........ . ...............:..•-•-:..----- . ----- ----•-•-- ..........._-------------_---------- -•-- -_-. ----------....----........--- -:............ <br /> ................................ I. •_. . <br /> r . <br /> _--_-- <br /> = ------------------- --- -......---•----.......:•-- • . •-•--•-------- ......---- w <br /> incl Inspection by - ... __ 'l ......-- -----•--•----- ••-•-•• -- <br /> H 13 24 Ii I F� REY.7/76 3M <br /> ,� SAN JOAQUIN LOCAL HEALTH DISTRICT ��;'�j <br />