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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOk SANITATION PERMIT <br /> ` - (Complete in Triplicate) <br /> Permit No. <br /> ----••--------- 1" <br /> Date Issued_".......:..._.-T- <br /> . _ _ ............ This Permit Expires 1 Year Front Date Issued <br /> Application Y lication 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 /> t . <br /> I,,-,,.,;JOB ADDRESS/LOCATION.....11 ._/3 _ .....I�f.•. .... . ----------- <br /> ----------------CENSUS TRACT......-------.................. <br /> T C J`v <br /> Owner's Name. _.I. O�------POPLLC4..- ----------- ...... ............ <br /> �---[-------- <br /> Address------ a � ....--- s....e .__..Vf A.IU- City �— Zip...: <br /> �j o� <br /> Contractor's Name.. #CIL .� .� C_D!lS �'------- License #-.c �9 �.r Phone <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- - -------------- - -----------• ---- <br /> Number of living units;........ ----Number of bedrooms...J....Garbage Grinder .5-._Lot Size------- ........... <br /> ! Water Supply: Public System and name.. .................... . r -. ---------•.--••----.Private`- <br /> - -------------- - -----_. �--------• ----....- ---�----•---•-•------ f; <br /> i Character of soil to a depth of 3 feet: . Sand [3 Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [11 <br /> Hardpan E] Adobes; aFili Material_-. -'.If yes, type'........_.•---------------- ---- <br /> 'f (Plot plan, showing size of lot, locatjon of system in elution to wells, buildings, etc. must be placed on reverse side.) = Y <br /> I NEW INSTALLATION: (No 'septic tank or seepage pit permitted if-public sewer issaavailable within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ( ] a` � �( <br /> Size..... �. -� -=-------- Liquid Depth <br /> Capacity/00-0.----- Type- M'atarial... --- -------No. Compartments-.-.1.2.1----- ----------- <br /> Distance to nearest: Well":... - .-- -.5f'_. -1 - ------Foundatio .-.'l _ Prop. Lined - <br /> / <br /> LEACHING LINE [ ] No. of Lines...- "-"-": ""..".--.Lengt of ea�h line.-..-. + . ..:.......:. otal Length ... _"... ....... <br /> j <br /> 'D' Box-f�a�a..Type Filter Material..` yepth Fil r Material.:_/. -.------ ---- <br /> / / Property Line"- /Q �Al <br /> Distance to nearest; Well---� . .......-...Foundation- "y �`y--- p Y <br /> O <br /> SEEPAGE PIT [ ] Depth.. --Diameter'. - ._...-..--.Number_-------------------- Rock Fi led Yeses No ❑ <br /> E ....Rack Size. ------------- <br /> - <br /> Water�epth......"-- . --------------- -- <br /> 1 Distance to nearest: Well.-AN- __ Foundation--- V <br /> Prop. Line <br /> I REPAIR/ADDITION (Prev. Sanitation Permit#.._"--""-...""" .. ""------ --- - - --- Date------..:.....------------.------.....----....� <br /> Septic Tank (Specify Requirements).............._--. <br /> Disposal Field (Specify Requirements)....------------------- _ -�'---------------••----............- -------------- - ----- - <br /> .---- ----- <br /> --------------- - <br /> of <br /> ( -----"-------------•----------------------•--------------- ---=--------- <br /> --------------------------- --------- - ---------------- ----...... --------------- -- --------------------------------------... <br /> . 1 <br /> (Draw existing and required addition on reverse side) <br /> I 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 Mules and Regulations of the `San Joaquin Local Health District. Home owner or licensed agents <br /> i signature certifies the following.' ! _ <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 Work n's Compensation laws of California." <br /> t <br /> Signed................ --------- --- ner <br /> .--- Ow <br /> 4 ...... <br /> iBy-----_------------ --- - ------- -=-=--­� Title_�...:'�-''•-------...... -----...._........--- <br /> (If other than owned <br /> FOR DEPARTMENT USE ONLY <br /> APPLCATION ACCEPTED BY ..---- DATE r"r}rO'7 <br /> DIVISION OF LAND NUMBE .. DATE....-------------- ---------- ---- -------- - <br /> ADDITIONAL COMMENTS.............. ----- ..-...-- .... <br /> s ---------------------- - ........... ----- --------------"".. <br /> -------------------------- ----------- ---- ------ . <br /> ------------------- - <br /> . ------- -- ..Date. .. <br /> -Inspection by - - <br /> - -�Fas21677 REV. 7176 3h <br /> 14 SAN JOAQUIN LOCAL HEALTH DISTRICT — <br />