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i <br /> RA. <br /> FSR t7FFICE USE: FOR OFFICE USE: <br /> APPLICATIOIAfOR SANITATION PERMIT -17 <br /> ------------------------ <br /> (Complete in Triplicate) Permit No. ._�S_______ <br /> ----------- -------------------------------------------- 6-a -7 <br /> Date <br /> -------------_---_---_--------_-------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health Dist`ictAor a permit to-construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No:5494ancf_.existing'Rules,and'-Regulations: <br /> JOB ADDRESS/ OCATI - --�� ENSUS TRACT----- ________ _______y <br /> Owner's Name- r <br /> 1.1� � ---------------Phone__©3462 3��- <br /> Address.-r-:?.7�'4`_t^�-.._. f <br /> --.���. � -- - --- ---------- --------- - ,City....-...� �----------------ZAP ---- -�'----- 90 <br /> - <br /> 1 + �f <br /> Contractor's Name__�<e— L� f �f"Q� IL'e�`S-- License #______/_____________Phone_.._ y'__= <br /> f ❑ C6�r erfFIf'I ❑ Trailer Court ❑ <br /> Installation will serve: ` Resident Motel", OtherQ �}'�p J_ __ -IT�lj'1_ <br /> CIA <br /> Number of living units____ __________Number of bedrooms- ___1---___Garbage Grinder--NQ_1ot Size---------__------- ---.----------.:r'._ -_._. _ <br /> " Water Supply::Public`System and name--------- ? ` 4 Private <br /> y <br /> Character of soil to a depth of 3 feet: Sand (�' Silt Clay ❑ Peau Sandy Loam E] Clay Loam E] <br /> ' Hardpan ❑ Adobe ❑._:! Fill Material_ �._.._It yes,type___------------------------------ <br /> (Plot <br /> ___________________________(Plot plan, showing size of-lo t,*locat_ ionf system It in relation to wel.is, buildings, etc. must be plced on revarse�s�ide.) <br /> 0E_W INSTALLATION: '(No septic tarfik or seepage pit permitted if public sewer is availableiwithin 200 feet,) �• <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size__ _ ^Liquid Depth--., <br /> iP ' <br /> Capacity-- - __-;-Type /+c J�I ___Material '-No. {Compartments', S <br /> i �� - ..J <br /> ------ -� } <br /> Distance to neares_AWeli__.____'sT � _____f___ __Fount#anon-, --------------Prop. Line___±/ _.___._.__ <br /> LEACHING LINE [ ] Na. of Lines.___....v"- Len th of each lin --____;.,. -' Total,;-Length.-.:__. FS_�__ <br /> g ' '"- _ " _. S <br /> 'D' Box__1______Type Filter Material//' _ epth Filter Material______ ` �._________________ __--------------____ <br /> Distance to nearest: Well_ ,1 _.--.____--Fou.n'dation ____ --------- Property Line___ _ ________________ <br /> Depth./o._ __ . Qiameter4f/_XJ_-----Number Z------------------- Rock Filled."jYeSX No❑ <br /> Water Table uepth-------------------------- o Rock Size----� �' .a---- � �=tom` <br /> Distance to nearest: Well__-� 40_________________________Foundation._13-_..__.____.____.Prop-Ain e '__._________ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------_----_----.----_-------_____.______.Date _____.._._.____________.___________) <br /> Septic Tank (Specify Requirements) ------ ---------- - --------------------------------------------- --------- ---------� <br /> DisposalField (Specify Requirements)-------------- ------- ------------------------------------------------------------------------------------------------------------------------------- <br /> --------------- ----------- ------ ---- ---- --- ------------------------------------------------------------------------------------------------- ------------------------ <br /> -------------------------------- <br /> --------------------------------------- ------ -- - ----- ------------------------------------- --------------------------------- - ---- ------------------------------------------- <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 Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performan of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become bje t' t rk b_. Com ensation laws of California." <br /> Signed---(7- �---- - ---- -- ----- ------ ----------Owner <br /> By---------------------------------------------------------------------- ---------Title ----- ----------- <br /> (If other than owner) <br /> R DEPARTMENT USE ONLY_ <br /> APPLICATION ACCEPTED BY------ 4DATE---._ Z <br /> DIVISION OF LAND NUMBER DATE <br /> e ADDITIONAL COMMENTS ----- ---- ----- --------------------------------------------- <br /> ----------------------------------------------------------------------------I-------------------------------------------------------------------------------------------------- ---------------------------------- <br /> -------- ------------------------------------------------------------------ <br /> ------- ------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------- -- ------ <br /> ---- ---- -- _ ------ - --- ------- <br /> ---------------- ---------- ------------------- --- -- ---- <br /> Final Y <br /> Inspection b -------------- ------------------------------------------- ---Date---- <br /> EH 13 24 L SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />