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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit 1 <br /> Date issued_.5__-3.__9 g ,( <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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION-------11172---Iib_9*'I1N.-'--------------------------- <br /> 4 .. <br /> - _ <br /> : � - ---� - '-- --- ---- `-�---.CEN US.TRACT ------------------------- <br /> Owner's Name------------------------ �r-a_ ------------------------------------------ -- ------._---.Phone-----SAX`���13------- <br /> Address <br /> ------ <br /> ..: <br /> Address------------- ------------ --------,7"- - --r:--- ---------- -1_'--------------------.citY--------- -------------------------Zip- T . ----- <br /> Contractor's Name------------------------ - '-License #--I-------------------- ---Phone ---------------- ---- --- <br /> -----------=------- - - --------------- <br /> Installation:wilf serve: Residence Xj Apartment House E] -Commercial ❑ -Trailer Court ❑ <br /> ......K._ Motel ❑. Other_t'-----==-------'= ;. <br /> Number of living units:------- ------ Number.of_bedrooms_._____Garbage Gririder._i Q_-'-Lot'Size.y_AJEWAK— __140x_ �- <br /> Water Supply: Public System-and name - ` Private Xt <br /> Character of soil to a depth of 3 feet: • Sand ❑ 'Silt❑ Clay ❑ Peaty Sandy Loam;f Clay Loam ❑ <br /> -Ha'rdpa'n-[]' Adobe 0 Fill Material__ ____=____If yes, type_------�_-__- --__ <br /> (Plot plan",',showing size of lot, location of.. system in relation to"wells, buildings, etc.,must be placed on reverse side.) ¢ ; <br /> NEW INSTALLATION: {No septic tank;or seepage pit permitted if'public sewer is available within 200 feet,} r..� <br /> PAC KAGEtTREATMENT, .�..� SEPTICTANK [,� Size-------------- ---------� '�' - Liquid Depth-:- �-- ------; � <br /> -x--Mate:vial- '"„ �= No. Compartments__`--------- --;--- -1 <br /> i .. bistance.to nearest:.Wel1j..;_- _Foundatio - : -.Prop. Line. = <br /> LEACHING LINE F[,:J f No'of:�Lines_ �� sLe gth of each line._ _______.___,Total•Length. <br /> I - --------------------------------------- <br /> Cil <br /> .• <br /> -- - -_�. <br /> OiF' <br /> . ___ -_-_-_- <br /> -__ <br /> a M --- ,---------------ox_ YPeitera eri - ------ ----- ------ <br /> Distanceto nearest: Well-ms - _- Foundation__ _ Property Line- <br /> SEEPAGE PIT [ ]' . Depth----------------Diameter____ --------- " Rock Filled .Yes ❑ No ❑ <br /> t • <br /> Wa#er Table.Depth____---------------- ---------- __ ___.Rock -Size <br /> t <br /> , <br /> = <br /> 'D`istancetonFoundation_ sProLi <br /> ne_ ___ear <br /> REPAIR ADQITION rev So Permit#________________ __- <br /> I( a <br /> / r Date <br /> Septic¢Tan:k (Specify Requirements[ - = - ----- ---------------- <br /> Disposdl Field (Specify Requirements);-•4-'0� -- ---`------- ------ - <br /> --------- --------;----- -- --- ----- -- <br /> [ !;; / f ;-- <br /> -------------------------- <br /> ------------------------------------ <br /> i a _ (Draw existing and required oddttioron reverse side) '? <br /> I hereby certify that I'have prepared-this application and that the :work will be done in"accordance with San Joaquin County # <br /> Ordinances, State jLaws land Rules and.Regulations of the San Joaquin Local Health District. Home owner or licensed agents ! <br /> signature,certifies the following: <br /> "I certify that in the performance ofithe work for whic this permit is issued, I shallnot employ any person in such manner as-, <br /> to become sub ect-to Workman's;Compap <br /> sation laws.-Of California." ; <br /> Signed_ ----- <br /> ( '. _ - -_ - �- _��~"Owner <br /> By--' - ` ---'----------------------------- - -- ---------------------------r7itle------------------ <br /> ------ --- --- ---- ----------- <br /> �, (I# other than owner) <br /> 1 FOR DERTM T-USE ONLY ." 1 <br /> APPLICATION ACCEPTED BY.............. d ------ ------�- --- ---- -------- DATE.-. '- •-- --- ----------------- <br /> ti <br /> DIVISION OF LAND NUMBER--------------------------- -_-�-----_ -----------`----------- -- :-------`------------------------ ------`.`-),b ,TE='-'-�-'---------i--- ------ <br /> ADDITIONAL COMMEVTS'o- -----------------------------� F - ------------- -------------------------------------- <br /> \. { <br /> " " " ------------------------------------ <br /> � <br /> Fina! Inspection -�----- -------------------------- <br /> 4 � -- -' ; -� _� - _ � <br /> r" 13 sat SAN JOAQUIN LOCAL HEALTH DISTRICT F8521h77 REV. 7/763M <br />