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r FOR OFFICE UST: FOR OFFICE USE: <br /> 2�1 A APPLICATION FOR SANITATION PERMIT / <br /> Permit No.._7�- <br /> �s� <br /> (complete in Triplicate) -- <br /> --- <br /> -- <br /> �Jaj' <br /> ------------------------------------ Date Issued_.7_0'7_0_T? <br /> r "- <br /> �. ° �� ���-�' ----_ -_ This Permit Expires 1 Year From Date Issued <br /> k � 1 <br /> r o the San Jaaquin Local.Health District for a permit to construct and install the work herein described. <br /> Application is hereby made t <br /> This application is made in-cornpliarice with Count Ordinance No. 549 and existing Rules and Regulations: _ <br /> SSC? ' �► ,,f--._ <br /> � SUS TRACT -- •---•--- ----- --------- <br /> JOB ADDRESS/LOCATION---- ----------- - ._-~ --.CEN <br /> Owner <br /> -- J7 <br /> 's Name.--- -- r-- --- ---._ >"yy_�--ca��'�- - � ---'------:- ----�-- -- - <br /> Phone-� ----- <br /> Address-----ALJ /.1- r. r!1 L�-Q- ------ - ---------- ----- ------City , --------- <br /> P i <br /> /� <br /> Contractor's Name._ 's�- <--✓ •C4t T =-License #_ fit - -.Phone <br /> __ 'o �( - <br /> I Installation•will serve: Residence Apartment House L] Commercial ❑ Trailer Court ❑ _ <br /> V7 1• MotelS❑. . Other----.'.--------­ "------------------: ----- <br /> ' 4 orbs e Grindar _C.SLot Size 1 --'F f <br /> Number.of livingiunits:_: Number of bedrooms G g <br /> - - ..k-. Private ' <br /> Water Supply: Public System and name =_- -----------------------------------, - <br /> i': it -..«_... —r V; ..+_ <br /> Character of soil-to a de oth.o,f-3.feet Sand - Silt Cla Peat F1Sandy Loam'❑ `"Clay Loam f( <br /> " Hardpan , Adobe E] Fill Material __ -If yes, type---'--_� ----- ------ -. r� <br /> (Plot plan,lshowing,size of lot, location of system in relation to wells rbuildings,'etc. must be placed on reverse'side} ZA <br /> t.a." 1 �) <br /> -_ : [_ <br /> NEW ,INSTALLATION: '{No;septic tank,or seepage�pirirtted'if public sewer is a a+Table within 200 feet,)t R ._Liquid Depth ---PACKAGE TREATMENT [w],' SEPTI ,TAN <br /> No: Com artments__:_-- ____ _.__ <br /> t �yCgpaeltY "Type 4 dWO--._Material lr i��!t p <br /> Dist6nce to nearest: Well ----------- --Foundation___�<:7;--_:r_____.- Prop. Line___ , ; <br /> 4: No. of Lines_.__----------- Length of each line.__ - ----- - -------TotialLength -- �' f---_--.------------ <br /> LEACHING LINE. L� D h F I M <br /> (.l.. ..;_. ...• � <br /> tK ; ;D' Box._.1._.__Type Filter Materiel__f-- p , <br /> ----- ---- - <br /> • � .-- ----, a tion i ter aterial__�� � <br /> o nearest: Well._ Founds Jf r `--- <br /> 1_ <br /> .. ': -- -Found nPropert`y <br /> • Distance t /� � ----- ----- ------ <br /> a Diameter. ------ - ---- Rock Filled yYes ❑ No`❑.0 <br /> �.. <br /> SEEPAGE PIT ( j Depth --,.._ <br /> 1 <br /> WaterTable Depth ____ ---- ---- � � ------------------------------------------------ t <br /> ' Di"stance'to nearest:Well----------- <br /> Foundation Pr"op. Line--------------------------- <br /> --------------------------- _ s <br /> REPAIR/ADDITION (Prev:Sanitation Permit#----------=---= --=--------=--- --------------Date_-:-----------;--_ ---------------- i------ --) t <br /> Septic Tank (Specify%Requirements);.--------------- - -- = <br /> ==: <br /> ----- ' --- -------------------------- <br /> Disposal Field (Specify Requ'rem;�nts)__...,_ ------------ ------- }y <br /> "rw _ ------------------------------------ <br /> ... _.. ' <br /> ----------------- ---�i`CSG �,.. r c a <br /> 1 ------------------- ---------------- --- -------------- <br /> ---------------------------------------------- ---------------------- ----:------ ---------------------------------------- <br /> x '' i (Draw existing and required addifiion 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 /> monner <br /> "I certify that in the performance-of.the�wo�k for which this permit is issued, .1 shall not employ any person in.such kas <br /> to become subject to.-Workman's Compensation.;laws of California." <br /> Signed---- ------ = --------- -=-------------- -- ------- <br /> , <br /> Owner { <br /> By k` - ----------------------------------- Title 1W&At _ - <br /> (I <br /> ���th"er wrier� <br /> '.FOWDEPARTMENT'USE ONLY,' <br /> APPLICATION ACCEPTED BY___(�ZJ <br /> -DATE. -=-/-/----77-7---- --f--- <br /> DIVISION OF LAND NUMBER:-- ------- ----------- - -------------------------'----.--- -----. = DATE... <br /> ADDITIONAL COMMENTS------ ------------------ ---------------------------------- <br /> -------- --------- <br /> = " - , <br /> ----------------------------------- ----------------------- _ <br /> 1 <br /> I - - ------e. --- ---------------------- <br /> ------------------- <br /> - = _ --------------- [ _ 7 <br /> - - ----- <br /> Final lnspection by:__�-_.__"- -- - <br /> a e---------------------- - -- <br /> EH 13 24 5 N JOAQUIN LOCAL,HEALTH .DISTRICT F&5 21677 REV.7/76 3M <br />