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FOR OFFICE USE: FOR OFFICE USE. <br /> AP, <br /> OLICATION FOR SANITATION PERMIT ` <br /> Q-------- ........................ Permit <br /> �� � /�' ''Complete in Triplicate! <br /> ------- - ------ <br /> Date Issued.7__-2-3�?9 <br /> ......................................................... This Permit Expires I Year From Date Issued <br /> i <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. Y <br /> This application is made in complionce.with County Ordinance No. 549 and existing Rules and Regulations:. <br /> JOB ADDRESS/LOCATION.... 7..I�� _'. � .TrCI.....44& ..CENSUS TRACT <br /> Owner's Nome,._.. ..... .. <br /> 77 - `� /,6. �A11r PA......Phone..�3Q190!4- <br /> xftr.1..: - '" y � E . �, t <br /> .n ` - zip _.....Addresstx /.�L?C 77V... �ty. <br /> _ <br /> Contractor's Name--- !,.Q..... <br /> ............................License <br /> t <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial A Trailer Court ❑ <br /> Motel ❑ Other.......... ------ -_------------------ <br /> - LoSize -......-. .... ..:.Number of living units:..-_-..........Number of bedrooms.-.._.:r- Garbage-Grinder---. . — <br /> Water Supply: Public System and name............. ------- -:--•------ .......................................------......._.. ...... -----.-.Private [ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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,] .-C <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] --------------------------- ----Liquid Depth----------------------------- <br /> Capacity- ............Type................ Material------------• ---.....--..No. Compartments_._�-----•................ <br /> Y� Distance to nearest': Well-L..........................•-------------Foundation............ ..---........Arop. Line....-.....--..-.-- l <br /> LEACHING LINE [ ] No. of Lines................... ' _..+' Length of each line--------_--------------------Total Length ....----,--......_.. ---- �. <br /> -------------- <br /> 'D' Box............Type Filter,Material_:............ ... Depth Filter Material---_------------ .---------.....------ .------..-------------- <br /> '� Distance to nearest: Well-'------------------------- Foundation............................ p <br /> r ertY d k Filled 'Yes <br /> SEEPAGE PIT [ ] Depth Diameter----- •--•------ --.Number ------------------ ❑ No ED <br /> Table Depth-------_---------•-•-••------- Rack Size....._ i <br /> Distance to nearest: Well._._-------------------------------------Foundation......... .... .........-.Prop. Line.-..---.....-------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------- ........... .........Date---•-------_------------- -----------] <br /> SepticTank (Specify Requirementsl.__ --------------- --- ----------------------- ---------------- ------------ .........................=........................... <br /> Disposal Field [Specify Requirements]---> - -k------(v0-��)I-Q2. -.77�2A1.p�1----�1T....7`Q-.., IA. <br /> IC -----------------------------------------,r-/-- -------- -------- ----------- --------------------I---------- ..... -i------------------------------ ----•-------­­.__1­.......... <br /> _---------------------------- ----------------------­------ -­------------- ............ ------------------------------------------ <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 County <br /> Ordinances, State Laws, and Rules 'and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certif_ie'sthe following: `T <br /> "I certifythat in the of the work for which this permit is issued, I shall not employ any person in such manner as <br /> P <br /> to became s ]ect to brkman's Co�m/�pe atipn laws of California." E <br /> Signed-. }:=� ':1 { 7" --•----•• 1. Owner <br /> ,, r L.v Tirle <br /> ' (lf other than owner[ t - _----I <br /> 1 .t <br /> FO DEP. RTMENT USE CY O <br /> APPLICATION ACCEPTED BY_------ --- --- ---- - ------------ --------------- ----------..DATE ----... .7 . . .. .. <br /> DIVISION OF LAND NUMBER--------- --- ----- ----- - - ..-.DATE ......... .......... <br /> ADDITIONALCOMMENTS ---•-_-------------- -----....._--------------- ----------------•-...--------.....-----------------•-------..----------------- -------- <br /> ---•-------------- •---•------•--- ------------------------------------------ -------- <br /> ... <br /> ------------------------------------------------ ----- ------ ----.....---------.-------------..-.... -------- --• --------------- -------------- --------- <br /> .............. <br /> ---------------------------------------------------�_ <br /> - - --------• ..Date-- ................. <br /> Fula! Insgectton by ......--- I <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ' F&S 21677 REV. 7/76 7M <br />