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FOR OFFICE USE: FOR OFFICE.USE.' <br /> �- APPLICATION FOR SANITATION PERMIT �i <br /> ---"----------------------------------------------- - - ' �—y k <br /> (Complete in Triplicate) Permit No-_.__-/_fJ______�3 `___ <br /> Date Issued <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 compliap4sp with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.r.,'®: . /fie 1 ), teF------�-Y�: - - CENSUS TRACTOwner's Name-------C�------- 7 J! _oc�jt-Ztz ----------------------------------- ----------------Phone----+-------------- -t---- <br /> Address---- I '2--- ---- 1.._-•------- - --- <br /> ' � n - O5 <br /> . , . �`-�';�- � - City--- ��. -� ;� - - - -:--------_--��P-------------------- --�-� <br /> Contractor±: Name-.---- ----------- .... <br /> .� . . . <br /> ----------- <br /> /�--�'��---�`-[,Jl.�-!�_� ---°------=-------License #�_�1�.�} __Phone <br /> Installation will serve: Residence. Apartment Ho ❑ :Commercial ❑ Trailer Court ❑ t i <br /> .M *._. . ...<. Motel ❑ Other------------ " <br /> r <br /> Number of ivin units____ ___________ Number of bedroomL3- _Garbage Grim)_ t Size'—J_ 0M.�. >.---------------------------------- <br /> Water <br /> ____:______ p <br /> y - <br /> Water 5u l Public S�stem and name_____.__ _ _ - a�. <br /> Supply. ; y . -. t :' Privates <br /> Character of soil to a depth of 3 feet: • Sand ❑ Silt 0 Clay ❑ : Peat 0 Sandy Loam 0 "Clay Loam <br /> Hgrdpan ❑ ' Adobe ❑ Fill Material._.___.__ .If yes, yPe___ l <br /> _ s a <br /> (Plot plan, showing size of lot, location of system in relation o�wells, buildin etc.mus`t be,placed on reverse side.) <br /> NEW'INSTALLATION: (No septic tank'or seepage :pit permit ed `if public ewer is available_within 200 fe t,) <br /> PACKAGE TREATMENT"•[•] "SEPTIC TANK ' "'` "'� <br /> l [ ) ?' Size--- -. �-�-- --X'��------'------3---- Liquid Depth�?�-- �-- .-- <br /> sh;�i-,� Capacity-IL�-t'�:-----`TYPe +Q,( � Mate ial__.___ �________________No. Compartments- . ___ } <br /> e ) Distance'.to nearest: Well. i_F�ndation__/ Prop. ine.___= <br /> ---------- --- <br /> LEACHING LINE �.] No, of Lines-__- ) . _, __-___.__.Length of each li i_%V-� --.-.--_ ----Total Len th. __ -___ .__ -- <br /> 679 <br /> ;D' Bax_ �.:�_' Type Filter Material_ epth FjIter Material J___� ________::"__ _._-"____.-___ <br /> ... i l ,. . <br /> Distance to nearest: WellV�1` -- ound tion_t�1`~��- Pr'operty Line_1_�, --------- --1_3 <br /> F , r...M r_ .._ <br /> SEEPAGE:PI <br /> _�^) [ ] Depth---- -_ Diameter -_- Nu Aber -------------- Rock Filled Yes ❑ No ❑ <br /> .... ___ __ ___ _._ Sizet __ _________ <br /> g Water Table Depth.___ y_ _ ock ___-^'« „_-__.__ <br /> Distance'ta nearest: Well ------------- __ _._ _ __1,Foundation_ i '� Prop. `L`ine.___________-.___________._. <br /> i ---- --- -- ----- p ?_ <br /> REPAIRE*DITION (Preva Sanitation Permit#_- - i• Ddte_ _____ __- '___ ---------- <br /> Septic <br /> - -°-:-- <br /> Septic Tcink[(Specify Requite.�rneg% i -` -- ---- --- --------------------------------------- i - ------- ----------------- <br /> ---------- <br /> t y vr <br /> Disposal.Fi ldL((Speciify`Requirerne s ---------------- -- ------------------:-------:---------- � --------- ----- ---- - --------------------=---------- <br /> i� E - / <br /> a F _ <br /> ------------r---- i-------------' — - ------- ----- - ----- -- --------- - ---- <br /> ------------ - - --- --------- ---------------- --------------------------- <br /> L?ra existing and requ�`irAe <br /> d"additionlon revese side) <br /> I hereby certify that I hav pored--this app!ication-ond-4hat thelwork `wIII be dont in accordance with San Joaquin County <br /> Ordinances, State Laws, bind Rules and Regulations of the Sari.Joaquih Local fealth District. Home owner or licensed agents I <br /> signature certifies the following: <br /> l -� 0 : , <br /> "1 certify th t in the perfo hof-the worTc`foYr which this ermit �s issue l show not em Iqy any per n in such manner as <br /> to become subject,4o Workma Compensation laws of C fliFornia. ( """ � _ <br /> y Signed - <br /> By ------- - -------- ------- --:---- <br /> - - I--- -- --- ---=Titfe. -- <br /> (If other than owner) 4:, <br /> FO!A PARTME -T USE ONLY . .. <br /> :� ... } <br /> APPLICAT104"Cffff-E-D"B.Y `° --=- --- ------------- -------------I-- - -DATE.-------- /- - --- f <br /> DIVISION OF--L-A---N <br /> AND NUMBER- ------------------ -------DATE_.---------------- <br /> ADDITIONAL COMMENTS - ' `'-----� -`-- ---- ----- --------- -------------------- ---------------- ------- <br /> `+- <br /> ------ ----- ---5- ----_ --------------------- - <br /> . <br /> = --------------- -------- ------ ------------- ------------------------- ------------_--------- ------------------------------- ------- ----- ----------- --------------------------------- <br /> ---•--------------------------------------- r -.-- -. --- - - ------------- <br /> - <br /> Final.Ins ection b ��_. Date :1 .^ <br /> P Y:R- ^-------- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br /> i <br />