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4FFOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> F (Complete in Triplicate) Permit No. <br /> --------------------------- ---- --- - ---------------- <br /> Date This Permit 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...` 3:3O -- ---- S ---- X3 ;.6-1--�p1 1 --- ------.--CENSUjS TRACT------. ------------- <br /> Owner's <br /> ---- ------ -Owner's Name' Vxwely.... +' ------------- ---- <br /> Phone-S 9 =j % .. <br /> Address----------------- ----------- i -e---=-----------------..-:------------------ ----------- --------City ------- - -----------------------Zip----- .d; <br /> �', �� Tib o rvi 5� n� /'EL-Sgt �" 3- Y 2 <br /> Contractor's Name_-. - : -.... Y ---------License # ---..----------------Phone-_ - ---- ----------------------- <br /> Installation9will serve: Residence ®; Apartment House.❑ Commercial ❑ Trailer Court ❑ I ' <br /> ] ;, ..;....}. ,. . ....� Motel ❑ Other = ----- = <br /> Number of living units:--`--- ---..-- z ` Garbage Grinder----------'._Lot Size.-.--.1 H:ry---�----.--_ ------s <br /> _Number of bedrooms--_-___-,__.Garb) , <br /> Water Supply: Public System and name - ---­------------------------- -- -- -----------------:.•:.._ ---------'----- ---- - - ------ ---Private,® ' <br /> Character of soil to a depth of 3 feet: ' Sand [J Silt❑ Clay ❑ Peat ❑�`_ Sandy Loam ❑ Clay Loam ❑ <br /> ' Hardpan ❑_..._ ❑.: . If yes, type- -- <br /> 4 <br /> Hard an Adobe .Fill Material__ __� <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:"�,"L(No,•segC t6k or seepage pit permitted if public sewer is available within 200 feet,] <br /> W. <br /> PACKAGE TREATMENT [ ] = SEPTIC TANK .j•} $ize------------ ------------------ ' - 'Liquid Depth --- ►�d+ <br /> q <br /> .. I <br /> . . Capacity.----= =`--`- - `'Type- ,L --Ma cl -=- -:-:---- No: Compartments---------`----------- --- - - <br /> Distance to nearest: Well- Foundati.on---------------------------Prop, -Line.----------------------' <br /> LEACHING LINE [ ] D.B XLines_ -Type Filter M-------------------- <br /> Length of each line:` ..._ ...;.. ------_._....Total,.Length. :'____ ______________________ <br /> Depth Filter Material - 4 ' <br /> ---- -----{-----------Foundation.--"-------------------- ----Pr-oper,ty Line------------------------- <br /> ] .. stnce to neap )meter_: ,. .. ----- .-. --t--- <br /> SEEPAGE PIT 'Depth __-------.Number..........:................ Rock Filled ' Yes.❑ No ❑ <br /> Water Table Depth.--------- ----- ------------------------- --Rock <br /> # , Size.---_---=-------- <br /> ----- ------ <br /> " 'Distance to nearest:'Well"'---- ------------------ -- --------Foundation----- --------- - <br /> Prop. Line + <br /> REPAIR/ADDITION Prev:Sanitation Permit#'-----�eN3/�� -------_-----a------ate.LL--=----------` - -~-- :--."----- <br /> ' X%s Tim # <br /> Septic.Tank (Specify Requirements)- ----------------------- ----------------- e ��----- e----- --------- <br /> Disposal Field (Specify-Requirements)--- = - J� S �/+r/----=--- -- ---------------- -- ----------------------- ---- ------- --- ---- <br /> • i F I---- -------------------------- --` ' -- ----- --------------------------- ------------=--------------------------------- ------------R- ------------------ - ---- <br /> -----'----=----- ------ = ----- ------ -----. .------ ---------------- ------ <br /> " (Draw existing and required addition on reverse side) <br /> 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 certifies the following: <br /> ..I certify that in the perforniance.'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 . s9k /��rt! ----— s��- -=--=._---=------.Owner ) <br /> f" <br /> BYTitle ------------------- <br /> --------------------------------l n owner ; <br /> i f FOR DEPARTMENT USE ONLY i" A b <br /> 4 <br /> APPLICATION ACCEPTED 8Y - -----------------------------------------------------------DATE. ZQ ------------------ <br /> DIVISION <br /> ----=---- -DIVISION OF LAND NUMBER: ---- -------- -- ---.DATE---------------=--- <br /> ADDITIONALCOMMENTS------------------- --------------------------------------------------------- _------ ----------------- ------------------------------ ------------� <br /> ------------------------ ---- - ------ ---- <br /> --------------------------------- ----------------------------------------------------------- ----------- - ----- -------------- <br /> Final - <br /> by:-=--7:4�' - --e -- --- ----------------- - ------ - - Date.,— -------------------- <br /> �� <br /> 7 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />