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01- <br /> FOR <br /> FOR OFFICE USE: FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT <br /> ••- ---- <br /> .. . <br /> r Permit No-7 �:-S 7 <br /> (Complete in Triplicate) .. . . <br /> ...............-•-•.............. ............. t This Permit Expires 1 Year from Date Issued Date Issued_.?"_ `.?.-12 <br />' Application is hereby made to.the Sal,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. 54. 9 and existing Rules and Regulations: <br /> JOB ARQRES5/LOCATION-.-... ...... -------------------CENSUS TRAC . <br /> �/ V <br /> Owner's Name ....... . ._.._ ._. . . . <br /> - e ----- --- ----•---- •• --........ ---...... one .. ..... f <br /> f <br /> Address----- iq �--------- 1 --------- - --------------------- -=- - --- CityxATlloe.ipP. ZIP = ;----- <br /> f <br /> Contractors Name--- .... ._ _-.2:..�U��� ! �f��-- <br /> ------ ,,qq _. ....Phone <br /> .License #a6.�. <br /> Installationawill serve: Residence ❑ Apar#ment House ❑ Commercial ❑ Trailer Court ❑ I <br /> Motel <br /> ❑ Other-------------- --- - ------ � Jr'= <br /> Number of living units:..'/... _ Number of bedrooms.. /.:. .: ... . ..... --,---,-____.__,..- -. <br /> 7 F ---- F �- Garbage Grinder___.____._..Lot Siie__..C11 <br /> i Water Supply: Public System and narrme------------- -------------- ------:... ... .......................... Private <br /> Character of soil to a'depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam,fW Clay Loam ❑ <br /> Hard an Adobe Fill Material _ __-_ ....If yes,P ❑ ❑ Y YP - <br /> (Plot plan, showing size of lot, Location of system in relation to,wells, :buildings, etc. must.be placed on reverse side.) f <br /> NEW INSTALLATION s{No +septic tank or seepage pit permitted ifpublic sewer is available within 200 feet,) <br />` PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ; Size...............-........--------------------".-_-----i.-Liquid Depth...-'.----.---------..----- � <br /> .Capacity-.- ------...Type Material :N;o. Compartments........:.... ...-- } <br /> i <br /> Distance to nearest: Well--..----------- .. . Foundation..._.. Prop. Line__......_...__ _..._. ILA. <br /> - <br /> -LINE [ ] -.No. of Lines------- <br /> ----------- ......Length of each*line--•. . -- --• - - <br /> ---------- .-'Totalllength ._ .....---`----•--- -- ...... ...... f <br /> LEACHING t -i <br /> $'D' Box---.......f. Type Filter Material..t._.: ..-.!.......Depth Filter Material- -----------------------------------------------------------, U <br /> ' 'Distance to nearest: Well �.......__f Foundation_--------- --------1_-_..Property Line-.--.•---------._.._.....__..._. <br /> .. r _1.­ <br /> SEEPAGE PIT [ ] pepth------..........Diameter_.____.____... '_Number________.__-..____________.___ Rock Filled Yes ❑ No <br /> :Water Table Depth------------------------- -----------------------------Rock S4e.- `........_...... <br /> i , <br /> (Distaknce to nearest; Well............... .....................-------Foundation------- ------_Prop. <br /> . <br /> - -- � _ -- Line..--..-.------------------ <br /> REPAIR/ADDITION <br /> -------.--.-_REPAIR ADDITION (Prev. Sanitation ' ---- --- D - ---------- -'------- <br /> --- -� -- -..._) <br /> Septic Tank [Specify Requirements)----- ------ - ------------ ------------ -----------------------------------._..r.... = <br /> h <br /> Disposal Field (Specify Requirements) /`I TG' �L I 4- --------- !_.:_....... _, ca� �._..P�------ ----------- <br /> - - - .... <br /> ..----•. ............ ----------- ---------------'----•----'--- ----.�,.----..------------------------------------ --- ----"---.._ ._...._.__. <br /> -------- J -' - <br /> -------•------------ I I <br /> rs5.- --------------•------------------------- - - ---------- <br /> {Draw existing{ana-4cluired addition on reverse side],-.!. <br /> I hereby certify that I have p epared Aiis-application-arid-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: F�' <br /> "I certify that in the performance of the work for-which this' permit is Issued,•I shall not'einploy any person in such manner as i <br /> to become subject to W Compensation Jaws of California." <br /> Signed.... ` -- --`----`-------- t 1-------'-Owner- <br /> By-.----.-••------.....- - ... { r Title< .: -- ------ --- ------- -------------- <br /> c(If other than owner) <br /> FOR DEPARTMENT USE ONLY: <br /> APPLICATION ACCEPTED BY.......... . ...c... "r... DATE . r.rZp...- <br /> DIVISION-OF-LAND NUNC6ER'":"-'". .. "'. <br /> - - .......-----------=-----------......---------t....... ..---=- -- ---DATE. <br /> ADDITIONAL COMMENTS___............ .............. .. .. . ... <br /> __--:-.4 i U __ --------- <br /> --- <br /> ------------------_-------------_........._____ - --- _------__- <br /> Final lnspecrkon by:-- --- c .... ------------------ Q-.79.........- <br /> gate..... <br /> Eli 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M <br />