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,FOR OFFICE USE: <br /> I ilf APP ON FOR SANITATION PERMIT FOR OFFICE USE: <br /> it it (Complete in Triplicate} Permit No..77-_ -__- <br /> ----------- --- ----- �� <br /> 77 <br /> Ih Date Issued._( _ __--------- <br /> ---------------- <br /> -----------------------------_.__J ---"- his Permit Expires 1 Year From Date Issued <br /> t -------------- <br /> `` <br /> Application is hereby made.tol.the 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 /> iance .- �---�� <br /> JOB ADDRESS/LOCATION._--�� _6.�i/ - S 4' - ft- <br /> ----------------------- <br /> - CUS AI, -- -- ------------------------------ -------- .............. <br /> --- ---- - EN --- - <br /> i 5 TRACT <br /> Owner's Name j =h'-_-�� l•�. = � t Ph <br /> --- <br /> Address--'I -cJ "�c�_ CI 'J� <br /> one <br /> — ;. . R .. --- �...---- -- �iP ; <br /> city �1 S" � <br /> -- ------------------------------.._. <br /> Contractor s Name--------S_ ----------_-'--- License #..._ one <br /> Installation-will serve: Residenceo Apartment House E] Commercial ❑' ;Trailer Court ❑ <br /> Number� f-Iivin units:_.*___j I y Motel ❑ Other---------- ----------------------------""="-- <br /> f <br /> g _Number of. bedr.00ms:__n, Garbage.Grinde-r__..`A./a' Lot Size <br /> Wdter Su ply: Public System alnd.name--- <br /> _.-_- _ -- - Prlvat <br /> Character of soil to a depth of�3 feet: ; Sand ❑ Silt ❑ Clay.g Peat ❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan❑ ' AdobeX 4 Fill Material--_---------If yes, type-.-'---- <br /> ]Plot Ian, showin size of Iot,IIlocotion of s stem in relation to_wells, <br /> P g y buildings, etc. must be,placed on reverse side.} <br /> NEW INSTALLATION:a (No,septictic tank'or seepage pit permitted if pu Ric sewer is available <br /> le within 200 feet, <br /> PACKAGZO UE TREATMENT Size------------ - ----------- ------Liquid Dept <br /> h ------.-------- <br /> i <br /> 1� . <br /> } �-Capacitye. �r°�ST -` <br /> _ Matera _. o _U`--__'.__No. Compartments <br /> --------------------y <br /> Distance to nearest; WeII-_____. �_:"__________________________Foundation.__�d--_Ce- -.-Prop.. Line__ ._ <br /> ! � i <br /> P li' pp -------------- <br /> LEA <br /> CHINE LINE [ ] No. of Lines_'._ ____________________:Length of each line-------- ._ _.___"_.____.____.Total Length,_._._____�4-�1__ _ <br /> I� ------------- <br /> 1 <br /> t D' Of <br /> _!___;..Type Filter Material__- � �___Depth Filter Material_______-.__------ <br /> ------------- <br /> Dista <br /> __r __t_._.__________ <br /> Distance to nearest: Well._--------------------d U Foundation_-." -----------------Property Line--- <br /> ------------------------------ <br /> SEEPAGE <br /> _...____. -___ _-_ _ __ <br /> y3. <br /> SEEPAGE PIT [ ] Depth------ --""_Diameter.:._ ___"Number-------------------------------- Rock Filled Yes'❑ No <br /> Water�Tai ble Depth. ---=---------------------------=----------------- Rock Size---- ---------'------------------- <br /> d <br /> Distance to nearesf:WeIL:_____ -U_.0_____. <br /> --"-----------------Foundation--' .Pro_p. Line---------------------------- <br /> REPAIR/,ADDITION-(Prev. <br /> ---------------------- <br />' t l -- , <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------- --- :-------- ------^-"""_-:Date_..-_----------------- ] <br /> Septic Tank (Specify Requirements)------------ -=--=-=------ - --------- ----- = ' ' <br /> Dis`posai Field (Specify Requir encs)------------ __..____. - __________ --------- <br /> ---------- -------------- -- -- <br /> -------------- --------- <br /> I (Draw existing and required addition on reverse side) ' <br /> I hereby ,ertify that'I have prepared this application-and-that the work will b'e dome in accordance with San Joaquin County <br /> tY <br /> L Ordinances, State Laws, and; Rules and Regulations of: the. San Joaquin Local Health District, Home owner or licensed agents- <br /> signature ertifies the following: 4 <br /> i "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 /> t ned-------------- _l__ __ is n' Compensation laws of California." <br /> tobecome . b'ect to rkm Owner <br /> ,-- �yBY = ---------------- -------------=------- ----- ----Title <br /> ------.---- <br /> tI ---------------------- -------------------------------- <br /> (If other than owner] , <br /> �� FOR EPART� ENT USE ONLY <br /> } �P,PLICATION ACCEPTED BY__.:�.I - --.---- --------- --� --- - - -------------- -DATE.---- <br /> ---------------------- <br /> ------- <br /> �- -- ---- <br /> - <br /> IVISIONi[OF LAND NUMBER---I11i.1_:...---: ------ __ DATE <br /> - - ----- --- - - <br /> ----------------- --- --------=--------------------DATE------ ------:--- <br /> bITICNAL COMMENTS-_t­V <br /> .-- <br /> - ------- --- ----------------------------- <br /> - -- ---- -------- ---- ----------------- ----- --------------- <br /> spection bY= �� — . ----------- --- ---- ---Date--`------------ ----- ---.---- -=------------- <br /> i! I Q4 <br /> L - -,�"�.L <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />