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FOR OFFICE USE: FOR OFFICE USE: <br /> . `APPLICATION FOR SANITATION PERMIT 7 9 -S 7-53 <br /> (Complete in Triplicate) Permit No. ---------------- <br /> ........................................................ <br /> Date issued..:-.,;�."-'?-Y <br /> .'............................_.........._............... This Permit Expires 1 Year From Date Issued <br /> Application is liere}Sy'm&de'to.the San Joaquin Local�Health Dis"trict�fos a perm'if'fo cori`sirucfand-.iristal'l-the workher"ein described. <br /> This application is made in compliance.with County Ordinance No. 549 and.existing Rules and'Regula.tio s: <br /> JOB-AD DRESS/LOCATION :. !4 U4�.'"'"""""�---.CENSUS RACT7.=..?..... - <br /> + t ` - .Phone i5r ?3.`' ...... <br /> IV <br /> Owner's Name..... ,,.: --�- - - --' -- - , <br /> Address. ----- °�'�/ ' t i i .............................. <br /> ! CtyTk� J <br /> i #4?'1�. Phone� <br /> Contractor's Name_t. = E'1�� License i Vis, <br /> Installation will ser i�,e: Residence ❑ I Apartment House ❑ Commercial ❑ Trailer Court 0 _ <br /> ' � . Y Motl ❑ c Other--- .. ---------- <br /> e w t <br /> Number of living units:---i.'.-.--------NumbeAr of b6Jdrooms------.---- Garbage Grinder.............Lof-. IZe:_---- :.?Oe {, ......1--------- -- '----" <br /> 1 F ` {i, M ... A-.l it <br /> Supply: Public System an name:.--. ....1 ..---..=. .... ..: '' -------------------------------- - ---------- <br /> Water ;Private <br /> �s <br /> Character of soil toga d pTh -1eet: Sand ❑ Silt❑ Clay ❑ Pea#.❑ XSandy Loam , Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material.- ---- - <br /> es, type--- <br /> [Plot plan, showing size.of lot, location of system in relation is 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 <br /> 4� <br /> " _-...SEPT-I'C' NK [ '] Size ..-. Liquid Depth:` .. ..- <br /> PACKAGE TREATMENT [ ]--.. <br /> �-Ca dcit e ............. '-"°- Material No. Compartments <br /> t.r. p . y-'--------------- ----gyp i ;V <br /> K Distance to nearest: Weil'_'--` -------------- ---------- ----- Foundation-----" ......` Prop. Line - ;' <br /> LEACHING LINE ' i ] No. of Lines ................ ..._.'_-.Length of each line,.---•--'----•:------------ -- Tota! Length ....-----"---------- }---:-------'- <br /> 'D' Box__.. ....Type Filter Material----- ---" ..Depth Filter Material------- k " -- <br /> Distance,to-nearest: Well — .. Property Lina ......---. ....... <br /> : --'"` -4 - <br /> I-SEEPAGE-VITT [ ] Depth.._ . . ... _Diameter----------- Number-ndctticti---- ------------ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth --- �= •-------------- -----------Rock Size....... ....... ---------....:.----------- <br /> Distance <br /> - ------Distance to nearest: Welfl-'----------- ------------ ' ..........'Foundation.... ......:...Prop, Line-------------......... <br /> t ' <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.._' ..'---------------- --'-- -'-- Date------------------------------------------------ <br /> } i <br /> Septic Tank (Specify Requirements) . --------------- - ------------of "------"- ------ : y ¢' .- - � --•---' _...-- -'--- o <br /> Disposal Field (Specify Requirements) ..�. _�iGl?`.. �.C11Lr.- -- �= �` " " t <br /> _ j/��"(yam X <br /> • .................................... ...........L------_--------------- <br /> 4 {Draw existing and required addition on reverse side] .` i <br /> { 1I hereby certify that ! have prepared this application and that the work will be done in accordance 'with San Joaquin County <br /> Ordinances, State Laws, and Rules land Regulations of the San Joaquin Local Health Districtome owner or licensed agents <br /> signature certifies the following:; <br /> "1 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 sub'ect t Wo man's Comon pensatiI1aws of California." <br /> Signed------ l " '..-Owner <br /> i i--_--- ----- Title <br /> . <br /> (If other than owner) a <br /> E ! s FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _' ` '- -------' ..tr------- - ---------- DAT -..... <br /> ' �.— _. <br /> -- --: ._. ,DATE` ............_..--.-....-- <br /> DIVISION OF LAND NUAIiBER _ _...:_� ..:__..."...-. <br /> ADDITIONALCOMMENTS. •-----.....`. - :.....- ---------------- ------------' -----------.-...-----" ---- -------- <br /> t --- ------ --- - ---------- - --- ---------- -------- _---------- - ....._ . <br /> it --------------- f---------- ------- . ...... --- ------ <br /> (p.................................................... -------.. ..Date ---- ---��-7�-.7� --._.......-- <br /> Final Inspection by:._..--"-'------ - '------ <br /> ------------------------- "--------'- --------- <br /> EH %3 2e, SAN JOAQUIN LOCAL HEALTH DISTRICT S 21677 REV. 7/75 3M <br />