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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No...7-7-/ <br /> ------------------------------------- ------------------- <br /> Date Issued.__3-- <br /> --------------------------------------------------------- This Permit Expires 1 Year,From bate:lssued <br /> t„J } <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/L CATION_:.- r0-(4-C(?--- ------- ----- -- --- - ------- -- --CENSUS TRACT 1 <br /> i <br /> Owner's Name t-- ------------=------=-------- -------- ----- ---- ---- - -- ------- -- ---- ---- - ----f-hon'e---, a"4 <br /> _.,.. V--------- <br /> Address--- ........5.Znl ---------------- city.-. -�- f..-d -- <br /> --.--. <br /> , <br /> Contractor's Name--07�7e.;_-± alol - ; -- +---------------------------------License <br /> Installation will serve: } Residence R' Apartment House.❑ Commercial ❑ Trailer Court-E:]7t $ <br /> MotelOther------ --------- ----- --------- ------------- <br /> Number of living units:--�---_----__ Number of be'droos - Garbage Grinder---------- -Lot= <br /> Size_ _:AD <br /> --UA -o---- - ---- <br /> Water Supply: Public System land.name------------------------- ---------- ,---- - ------ - - ----- - ---Private Q1 <br /> ` Character of soil to a depth of 3 feet: Sand ❑ 'Silt(] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam F44/­ <br /> F <br /> / . i <br /> F Hardpan E] Adobe ❑ Fill Material_- If yes, type.----.--- _--___.__qs�.-___ { <br /> i R ' <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-' E(N6 sib pt'ic tank`or seepage :pit permitted if public sewer is availab'lel'i hin 200 feet,),,,) I <br /> PACKAGE TREATMENT" r rr I i Vl y I <br /> ( ] : SEPTIC TANK [�}� <br /> size -" '� f�"r -k�sn Liquid bept <br /> ' 4, -CapacityJ;LcZ�--- -- Type- _y- ,:Material-�Un +- No. C - r s:• °� ---------------+ <br /> } t <br /> 1 � i <br /> LEACHING LINE. [+� Not ofclineSnear�t: WeIL--- -L�Length of each,lina Four�ldation..- 6; ----.-� .-.Prop�Line-._l-s��__--""__-,O <br /> 1' <br /> [ 1 i - j O <br /> D' Box-�:q-�--T e Filter Materiag/---- .-//I�De t'�Q --��-- -�-Tota�eggth.-----�•ZO---------------------1-- <br /> Type Depth Filter M'ater:ia'I �/ -------------------------------- <br /> P <br /> -- -- - - ---.- -= <br /> L _ <br /> Distance,to nearest: Well-----13P..............- Foun4dtion =� t Rfoperty Line __ V f . <br /> --------------- <br /> Dep' :....Diametern-3 3------ Number --i-- - J _--:----- V Rock Filled Yes (� No [ <br /> SEEPAGE PIT L�'� Wath -Table -- ,.. .� �- --- -�--� - I-•--- <br /> 7�r . ------,Rock Size--- ----'- ------------------------------------ <br /> - <br /> ------- ---------------=----- x <br /> Depth---_---- ---' <br /> i/ f i f / / <br /> Distanceao nearest: Well----- -70_-___..--_---:------7- --..foundation-=s ------------------� -Prop. Line.--- ------------- <br /> l` <br /> REPAIR/ADDITION [Prev:Sanitation Permit#---------------------------------------------------iDate.------=-:-----:------'`-= ---------------- <br /> ­7 <br /> --------------- ` <br /> Tank (Specify Requirements).--�--_---- ----- -- -f ='---------------------------- -- ---------- --- ------------- <br /> Septic 1 <br /> F --"''---`----------------------- - --==-=-- - ------ <br /> 1' r <br /> Disposal Field (Specify Requirements)-------'--------------- , <br /> -------- ----------------------------------- ------------_-------------------------------------------------------- /:. - -- -------- <br /> --------- ---------------------------------------- --------------- -- --------- -- --- -------------------------------------- --- ----- ---------- -------------------- <br /> I l' (Draw existing and required addition on reverse side) <br /> hereby certify that.l 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: f f <br /> ..I certify that in 'the 0erforrii666e O'the!work for which"this' . rmit is issued, J shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of Xi lifornia.'.'. <br /> Signed-"-- �_ *_ --- ------- Owner <br /> -- -- -- --- --- - --------- <br /> t <br /> BY -y Title_ L!.l, G,K - <br /> (If other than owner) <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ _--� <br /> - - - ------------------------------------------- <br /> DATE �----------------------------------------- <br /> DIVISION <br /> 31-?? = ' <br /> DIVISION OF LAND NUMBER--------------- DATE--------------------.------.--------------------- <br /> ADDITION AL <br /> - -ADDITIONAL COMMENTS------------------------------------------- ---------------- -------------------------------' ----------.----------------- ---- ----- -------------------------- <br /> ------------------------------------- -- ----------------- <br /> -------- ------------------ --------------------- ----------------- ------------ ----- ----------- ------- -----------------:-------------------------- <br /> ----------------------------------------------- ------ --------------------------------- ----- ---------I----------------------------------------------- <br /> Final <br /> - -------- ------------ ------------- <br /> Final Inspection by:- _. .� . ,. . _ _-- Date -3 f <br /> F EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br /> � 4 <br />