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FOR OFFICE USE: C �- FOR OFFICE U5E- <br /> APPLICATION FOR SANITATION PERMIT _ .!;—;7 <br /> .......::....................................... <br /> „ ' (Complete in Triplicate) Permit No....7 ..... ...._.. F <br /> ......................................................... <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 perrAit to construct and install the work herein described. ; <br /> This application is made in compliance with Comity"Ordinance No"549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION..._._.4 ,. . <br /> A,E?n pYr. .........................:....CENSUS TRACT.............................. <br /> ....Phone.. 3/`•.. 1 <br /> Owner's Name............. . ....�iC� .S ' ...... p ,�. ...... <br /> 1rr1.�.��. .. -- - ._. ..14/..!'1... :.�/J...... .....:..:.............Ci ...``��....// .Phone....._ :.. .,. -..._... <br /> Address. .._....._. . ty.. ......_ wl l.. :............. p.......--�--- -.... <br /> Contractor's Name....... . ..1 `'Y-. . . . �( !f /.. License #.. v . �i• �� �Y <br /> Installation will serve: -Residence ApartmeM.House_[] Commercial ❑ Trc(iler Court ❑ <br /> Motel ❑ Other.-_-------- .."::;_.................... ..... <br /> Number of Irving•units:........�... .Number of bedrooms...._3...Garb I Grinder.. l�..Lot Size.... aQ...- ...6.;3 .- <br /> ft <br /> Water Supply: Public System and name..'.... ..................... ..._........--........._....._...r........Private 20— <br /> (16 <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay E]'-' Peat❑ Sandy Loam N Clay Loam ❑ <br /> - �- - --° 'Hardpan �-Adobe ❑ > i11 Material---- yes;-type:...........Z. ...... <br /> _ <br /> (Plot pton, showing size of lot, location of system in relation to wells buildings, etc. must be placed on reverse side.] <br /> NEW INSTAL;ATION: (No septic",tank or seepage pit permitted.-if public sewer is available within 200 feet,} <br /> �..�..r,...r r r <br /> �.- _ . ..� <br /> PACKAGE TREATMENT ( ] SEPTIC TANK T- Size:: :.J ...-._.....9_ ..t' X. .--•-•-•••••--- 9 A <br /> ...Liquid De th... _Q........ ...... <br /> . ,' ! -Capacity% 0......Type--��F.C/�.f..Material...�.C1xt_C+P��I�..:No. Compartments...:_..Z:--............ ...... <br /> r <br /> 1 vDistance to nearest: 1Nell..........1. .Q.�............:...._.Foundation..._../..Q ......Prop. Line__..:E.dp-.... ..... <br /> LEACHING LINE ' ( ) No. of Lines,!!f . .:.3:7. .............Length of each line.......Y.0..............Total Length . /.. -57_..._........__. _... <br /> w i s.r <br /> 'D' Box_..r.......Type Filter Material '; t Qepth Fitter Mater"al.....1��........................... <br /> J ...�........ <br /> Distanceto nearest: Well....AQ.0..... . .......Foundation...... -Y-----.------ Property Line..... .0....... <br /> ock Filled Yes ❑ No <br /> SEEPAGE PIT [ ] Depth...;2..J-...Diameter..__3?9..........Number.......5-.................... RL� <br /> Water Table Depth. ....................... .........Rock Size..... ..................................... / <br /> 3 <br /> Distance'to nearest: Well......�.lQ�..........................Foundation-.----�.�..........Prop- Line..uf..d-;..-<-.....---.. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#........ ................... -.... ...............Date............................... ..I........._.) f <br /> Septic Tank (.Specify Requirements)-••••••••!-•••••----- ................................__.......-_-.•-........................... .... <br /> . <br /> Disposal Field (Specify Requirements)-...1...............: .....................................................--;----- -............. . .......... ... . {� <br /> _............ ..... .. <br /> t <br /> ...................a... _..... - -------.-------- .. -•--------.---- - <br /> 1 <br /> (Draw,existing and required addition on reverse side <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensedi4ent" <br /> signature certifies the following: ' <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become `subject to Workman's Compensation laws of California." <br /> Signed... � ' .. Owner <br /> 0 _ . NTitle.... <br /> By....... h ............ <br /> �4J... .. <br /> i <br /> t <br /> (If other than owner) 1 <br /> _EOR DEP RTMENT SE ONLY <br /> APPLICATION ACCEPTED BY_:.:_......... . .-fir.: _._ _. <br /> .... ..._ ... DATE ._....� ..c�-�. ... .. ................. <br /> DIVISION OF LAND NUMBER......................... <br /> DATE........ ........... <br /> -DITIONAL COMMENTS...................:. ........................................ <br /> ........._......._. . <br /> ..................... <br /> ............................................•---......... ----......._..._......--•--•----•-.................... _ <br /> ............... . <br /> ............... ..................... r.................- .........-_-..-.-•---------•.------------••----• -•- - -----... ... .......... <br /> �� ? ' � . <br /> Final lnspecFion by:... ..:.... . ...._..Date...Z:.`................................. . <br /> .... ........--• <br /> EH 13 24 t SAN JOAQUIN LOCAL HEALTH DISTRICT fas 21677 REV. 7/76 3M <br />