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10 FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT p <br /> Permit No.._71-:-7?�--- <br /> ------------------------ <br /> (Complete in Triplicate) <br /> Date Issued,/—3/': -- -- <br /> ----------------------- <br /> _ This Permit Expires 1 Year From Date issued <br /> -------------- ------ ----- ------------- -- <br /> i <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit toRules construct and install the work her <br /> described. <br /> p p <br /> llcation is made in compliance with County Ordinance N� o. 549 and existing Rules and Regulations: <br /> This app ' <br /> pp --- - --------------- CENSUS TRACT <br /> JOB ADDRESS/LOCATION. - -!- - . "' - <br /> pp <br /> � -- - ---Phone_- ---- ----- --� <br /> Q <br /> Owner's Name --- j ----------- <br /> 11T, I!...- c <br /> 71 "--- <br /> Address_.°Z s F • t ®`Z� ✓ -- ----- <br /> s •- f <br /> : x� Phone-A-1430 <br /> 3Q <br /> _ - License #- <br /> CXS (_3 <br /> a for N <br /> � Resl�ence jK Apartment House❑ Commercial Trailer Court ❑ : I <br /> llation.w111,serve: <br /> t Motel ❑ Other_:"= =----------- -------- <br /> ------ a✓ , <br /> s / ❑❑ <br /> e Grinder_=. ;_Lot Size 1 " J �.:_..t-^ _ - e'� . <br /> Number of living units:_..__.-_.- .--Number,of bedrooms_.t? g `� <br /> _-._..Garbo S�_j___Priva <br /> Water Supply: Public System n`d�name <br /> Pp Y <br /> Silt Cla Peat❑ y Sandy Loam ❑ Clay Loamj <br /> Character of soiG to a depth of 3yfeet. } Sand ❑ ;Y g.., _ Y e---, ---------- -- - t <br /> Hard an ❑ ` Adobe.❑ k Fill Material ------- <br /> es,typ <br /> ± p : ¢¢ <br /> size of lot, location of system in relation to wells, bui.ldin.gsy etj.:mus f be placed on re ers F side.) <br /> (Plot plan, showing s `"' feet,) i. <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted 'sf pubesewer 's available within y <br /> iLiquidDepth.SEPTIC TANK Size---/_;a PACKAGE TREATMENT [ ] rt ts- - -- -- ---- ---- -- <br /> �_--Materials No. Compo m 'n <br /> Ca acct �®d ---:Type----------- ----- - <br /> p Y <br /> I <br /> ---- -F,ound�atipn_. u1Prop. Line__Gt�` -- - <br /> e ! <br /> Distance to nearest: Weli.1=-- !d:T-----.---------- <br /> 1 t7w /__..Total Length--------- ------------------!- <br /> -� -Length of each Imo __ , r <br /> LEACHING LINE [ ] _ No. of.Lines_.. -.►� - . g ^_ _ ----------- <br /> ------------ <br /> 'D' <br /> -__-_ <br /> .. . v <br /> D' Box_.._j.. .. Type Filter Material �-t[ �S D.ept�wF.ilter?Material..1 .: <br /> i -- ► D--_ .- -- ---.Pr pertyline ..So ------ <br /> - <br /> _ :-_ Foundation, <br /> Distance,to nearest Well =- v .^ 111 <br /> ` i - .— .• <br /> R kF' ed Yes � ❑� <br /> De th ----Diameter. Number <br /> SEEPAGE P17 t[ l p• _ _ 1ze---- ---------------------------------------- <br /> i <br /> . .... <br /> . Rocks ..... � , 000 <br /> 4 .___.-_.._"...............• ,SXR. -.•�., __.._ <br /> Water Table Depth--- - --- ------- <br /> f <br /> Dist nearest: Wel!- ----------------------------- --- - <br /> Foundation..__ ---__--r-- 7 .Prop. Lin <br /> �Founcla <br /> t <br /> R -'.. - - : Date �(_- 1. , <br /> r REPAIR/ADDITION (Prev:-Sanitation Permit#--------------- -------- ---- <br /> ---------- <br /> ' - - - 1 - - -- ---------- -------- ---- <br /> Septic Tank (specify Requlrementsl- - -. -- ----------------------------- - ----- --- <br /> { i ".__.-- __".__...__".__.-__"_______________ <br /> - --------------- l r <br /> Disposal Field (Specify Requirements)-.__..- _- . <br /> f -- ------------------------ - ------ <br /> ------------------------------------------------- <br /> -- <br /> ---- <br /> --------------------------- ------: -------------------- <br /> -------- <br /> 6 - ----------------------------------- <br /> ------- 4 -: ' <br /> - - -- <br /> ii "�" " `(Draw existing and required addition on reverse side} t <br /> I hereby certify11jot-l-ha'Ve-prepared-this-app)ation-and-that-.the ',oOi-v�v�llbhe do e-in-accordance wo owner <br /> Joaqu ndCounts <br /> Ordinances,' State` Laws, and Rules and Regulations of the San Jacquin Local H;ealth District. Horne owner or licensed}agents <br /> signature certifies the following: <br /> "! certify► that in the performance6f:the work for which this permit is issued,.I shall not employ any person in such manner as <br /> to becom b'ect to Wor man's Compensation laws 9f California." - <br /> . <br /> lOwn <br /> ned. f er <br /> Sig <br /> __ itl e.!.�! ----- --. __ -- <br /> k <br /> ' (If other than`owner) <br /> 1 _ 'FOR DEPARTMENT USE ONLY <br /> t <br /> q <br /> i DATE.- - 7l- - <br /> APPLICATION ACCEPTED BY -- '- ------ - E <br /> -- ---------------------- ---- <br /> DATE.__.---:. ---- ----------------------- <br /> DIVISION OF LAND NUMBER-- -- -- --=------------ ------------------ ------- <br /> ' <br /> - ------------------ <br /> ----------------- <br /> ADDITIONAL COMMENTS- ------- ------------------------------ ------ <br /> I ----- ---------------- .------------------ -- <br /> -------------- <br /> - -- <br /> - -------- <br /> ------- ---- - <br /> ' --------------------------------------------------------------------------------------- <br /> ----------------- <br /> / - <br /> --- -�------- --------------- ------ --- --- �- - ..., .. �..- �-..Dat _ -- --- - ---- - - -- ----- <br /> Final Inspection by;. -�` -- <br /> - F85 21677 REV. 7/76 <br /> EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />