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FOR OFFICE USE: { ]�SANITATION PERMITFOR OFFICE USE: <br /> - <br /> ----------------- --------------------------------- APPLICATION FOR--- <br /> Permit No._,Z92= _ <br /> >3_ <br /> -------------------------------------------------------- <br /> (Complete in Triplicate) <br /> Date <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 G T • O G/----- ------ ' �V_e- I(,,6 CENSUS TRACT <br /> Owner's Name------- -------`-o-6/v.------- ------------------ -----------------------------------Phone_-$34 `0 179 <br /> Address-- 30�-CQe-----)11_s5c?A/_----.-el- ---------------------------------------City---7, c - Zip--- -------------------------- <br /> Contractor's Name______ i_l� T/r7rllSoy-- - ----------------------------License #_�E6-. G_-----Phone_✓ ' 3."__ �' ' <br /> Installation will serve: Residence® Apartment House.❑ Commercial ❑ Trailer Court ❑ Q , <br /> Motel ❑ Other---------------------------------------------- lam+ <br /> Number of living units:_____J___.__ Number of bedrooms----/------Garbage Grinder______-___Lot Size------------------__.____.________-___.______________ <br /> Water Supply: Public System and name--------------SIT.-!'?'--C------------------------- -----------------------------------------------------Private A <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth_----------.: ------------ <br /> Capacity---------------------Type-------------- <br /> ___________Capacity---------------------TYPe------------- -------_Material-------------------------No. Compartments--- ----------------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line---------------------------- 5 <br /> LEACHING LINE [ ] No. of Lines____------------------------ Length of each line-------------------------------Total Length---------------------------------------- <br /> 'D' Box------------Type Filter Material--------------------Depth Filter Material----------------------- ---------------------------------------- fi <br /> Distance to nearest: Well---------------_------------Foundation----.------------------------Property Line------------------------------------ C <br /> SEEPAGE PIT [ ] Depth_.--------------Diameter.-------------------Number-.------------------------------ Rock Filled Yes ❑ No ❑ S' <br /> WaterTable Depth----------------------- --------------------------------Rock Size--------------------------------------------- <br /> Distance to nearest: Well_______-------------------------------------------Foundation--------------------------Prop. Line______________-__________ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_--_________._-__..___---_-__-_--__._______-Date____________________________-______________) <br /> Septic Tank (Specify Requirements)----------------------------------------- --------------------------------_ <br /> Disposal Field (Specify Requirements)._------/_ 7i344-------- r--.--. ,mss-----�oWW".TOyq�------T°-------------------------- <br /> /C,>(i ST1N � <br /> -------------------------------------------------- ---------------- S- G'M - - - -- --cam <br /> ---------------------------------------------------------------- -------------------------------------------------------------- --- o <br /> ---------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) o <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County}C <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 /> 0 <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-------fi-_/74,v-,,-y ------v&- Soey-------------------- ----------Owner <br /> By--------- ------ - ----- -- -- --- ------ -- --------------------------------------------Title------------------------------------------------------------------------ <br /> (1 o than owner) <br /> FOR RTMENT LJSE ONLY <br /> APPLICATION ACCEPTED BY- - -- - - -------- - - --- --- -----DATE.- --- -00.-?��--/--- <br /> DIVISION OF LAND NUMBER. ----------------------------- -------------------------- ----------------------DATE----------------------------------------------- <br /> ADDITIONAL COMMENTS---------------- - - <br /> --------------------------------------------------------------------------------------------------------------- - - - - - <br /> -------- ----------------------------------- -- ----------------- ----- -------- <br /> e <br /> __.. - ---- -----.-. _ <br /> -----------------------.--------------'_____. .------ --------- <br /> Inspection by:----- > Date- <br /> Final1"= <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 776 See <br />