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r r. . <br /> p 'FOR OFFICE USE: � rK � �(}� <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> tT I <br /> .....-................... . ... .... ...._,....._.,. Permit No..- <br /> 1 ° (Complete 'r Triplicate { <br /> �• �� <br /> % }} t Date lssued.b'( _ ? ...-... <br /> This Permit_Ekpiies l-Ye—ior'From Date Issued <br /> 1 � _ � <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 CountyOrdinance,No.X49 and existing Rules and Regulations: <br /> =T inert.. _ <br /> JOB ADDRESS/LOCATION........... (. .� ........... ...... a.V y J } CENSUSJRACT..._..._..-:,....__ ...�.... <br /> Owner s ne ��-- _ <br /> Address........ <br /> .. . b .. ... _ .--'.. l•t 3_. H!2 tJ-.City <br /> ` �#' 1�- .- zip <br /> s 3 Contractor's Nome : .. . . .........._,._Ca,LS'�-al:. - �:T3 C`�C} ' e �._4 .'.�- <br /> installation will serve: ResidenceApartment Aouse..[l_ Commercial 1­71 -Trailer Court <br /> r <br /> MoteI'Ff 1" - Other----- --........ - <br /> I .tVumber of!lying unrts:.:_. _-.....Num .. g Grin <br /> rinde _ �t' <br /> Lo#'.Size....... ; .............. <br /> Water Supply. Public System and name---- , .`.- <br /> Private <br /> Character of soil to a depth of 3 feet: Sond ❑ :Silt❑ Clay❑ Peat[] Sandy Loam Clay Loom (� <br /> s Hardpan u_. Adobe L' Fill Matericl.._......__If es, e-..v_...-.',...._.....--:__---. i <br /> c t c <br /> (Plot plan, showing size of lot, location of system in relation to:wells, buildings,*etc.'must be`place'ti:on reverse side.) <br /> NEW INSTALLATION: JNoc sseptic tank or seepdge pit'permitted if public seer is available within 200 feet,) <br /> PACKAGE TREATMENT l(—J SEI�TIC TANK 1 -i-- :--� ¢ <br /> [ Size..__:_.. :_. . _ - . . Depth.__,. <br /> • C-apocityi.. .. _ ` Type„�+ � -:........:-Materiol . ...... c$ No. Compartments........................_-._._ ..� <br /> Distance to nearest: We "�` .'. . -• Foundcrtian...;..�-'-c.—_.:-..Prop`rLine...................•-•------ <br /> LEACHING LINE T <br /> [ J No. of Lines.__._...:_•,.-- ng f eco lie ���...Tot6l Length <br /> _-___:_Type �... � <br /> y .._. <br /> "D' Box_ F,(ter Material,. ... Filter M,ateraa"..... -•- <br /> Distance, n nearest Well,:'...­! Foundation_.... _ Pop,ty Line. <br /> ;:." .-. _ ,-...__ ., `,.,sem; 1t' <br /> SEEPAGE PIT ~� „1 <br /> j ) Depth.._.;. -.. .. Diamefier s. . Number---..-._:...... ........... Rock Filled Yes iJ No <br /> . . Wafter Table Depth............... .. ......... <br /> nLe <br /> tr __._._._... -....---•.........;...,..�........._.Date- ....,--�...—. �a_�'.__'.•3.i�r <br /> oundaDistanceoas "e .... .._.. otion °.':-.-... 7 •.=_-_.•.Pmarce•: <br /> = - <br /> -{=-C <br /> REPAIR/ADDITION (Prey. Sanitation Permit#- _ .L r <br /> Septic Tank (Specify Requirements).' •----- ,_"_ :...-.._ .?1- :G C�'f.:_f� . " .�.. <br /> Disposal Field (Specify Requiremt)ts). . 1 �?_.11_ Y.. .�..._-••� ` 'T � - <br /> ::; - ---:------ - .-::- _.-•t. :rte -=-'7L?.-_.. � ---....,�• ��-�.�_izle�.• _. <br /> s (Diow existing and required 6i dclitibn,on reverse side) <br /> I hereby certify,thdt L/h'ave preptired this application and that the••work will be•done in acc lydan+ce with Son Joaquin County <br /> %� � <br /> Ordinances, State Laws; and Rules and Regulations of the, San Joaquin Local Heattk Dist�ric..t.'Ha iye�"' ner`or licensed agents <br /> signature certifies the follawing: 1 <br /> 1 ' <br /> "I certify that in the tfeiforrnonce'of the work for which this'periiiit is issuidy.I ai>a11 not empl�y any I+ersen n such manner <br /> to become subject o work.an's'Compensation laws of California," 1 #as <br /> }} t <br /> Signed._.-._..• -. .. 1 ✓ti.r� <br /> BY-1...... _.:._ _ �.. <br /> (If other than owner) r` , <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.-_ - ^� <br /> :... ............................. DATE.. __.. <br /> DIVISION OF LAND NUMBER......- .. . -•--•--,-,- - <br /> ....DATE.-:.. . --... ............... ..- ..;... - <br /> ADDITIONAL COMMENTS_.-.___ ._._... __.-_- <br /> :._. <br /> .........:... <br /> .......-... _... <br /> ... ...-, ,r /r --- - . -_.-.�....�-..�.,...._.._.--_,..... _ ._. -- <br /> � .L .fFinal Inspection-by: / te . Date.. <br /> Etrs S <br /> AN JOAO <br /> LOCAL HEALTH DISTRICT r 577 REV.7176 3m <br />