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vE l <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------- Permit <br /> {Complete��in Triplicate) -- <br /> ­----------------------------------- ----------------- <br /> - Date Issued./,%2-.-f-v2-7o <br /> ----------------_____ ___________________________________ This Permit Expires, 1, Year From Date Issued <br /> Application 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 /> JO_B.,ADDRESS/LOCATION„ . ,C l <br /> i - " }- - - _CENSUS TRACT.-- -- -- -----. <br /> G" _ -------------------------- - Phone- <br /> Owner's <br /> Name__ tY� -- --- --- -- ----- ------ - P- <br /> vZ ------------- <br /> Address-------� - ....-----�r----------`-� ,.. .Ci �,S`� *?.4 <br /> f # _ -tl/.. 1 Phone AI I <br /> Contractor's Name - 1� .� ``.'cz / License --1'----.�J'.2 c----� <br /> Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> t . Motel 0 Other _ . <br /> Number of living units:--_,..,/_____Number ofdrooms ----Garbage Grinder--- -Lot Size-- - ------- ------ .............._-- <br /> E ! � <br /> Water Supply: Public System and:name f ! Private ❑ <br /> Character of soil to a depth of,3 feet: Sand ❑ '.Silt E] Glay E] Peat E] Sandy Loam 0 -Clay Loam El'" , r <br /> Hardpan ❑ Adobe Fill Material...t''i~_,t-f yes, type_______________ a <br /> f <br /> (Plot plan, showing size of lot) location of system inn relation to wells, buildilh;gs,.etc. must be,.placed on reverse side.) ' <br /> NEW INSTALLATION: (No septic tank or seepagerpit permit ed if public sewerais available within 200 feet,) <br /> / M <br /> PACKAGE TREATMENT [ "} 'SEPTIC TANK [ ]Z;-etS rSize__ _____________________ -.---_____--Liquid Depth_-------_-- -- <br /> --------- - <br /> Capacity----------- TYPe-- -------------- .Material- ------------------- -- Compartments---------------'------------------- <br /> Distance:to nearest: Well---------------------------------------.----Foundation-- .---------------_-•_--.Prop. Line- -----_-- <br /> LEACHING LINNo. of Lil nes _ <br /> ___ __.------- . Length of each line.------ Q. T---_.Total Length.--,_�'-_-- _-_--------_-._ <br /> E• j <br /> 'D' Box.k` '___Type Filter Materialli- _-----Depth Filter Mator.ial.--�- F� .-"-.---------_-._---._------------------- <br /> r � t <br /> ' .Distances to nearest: Well_-_ ✓ -----Foundation-._l -!---- ------------ <br /> Property'Line--\S-.__------__--_____-.___-.- <br /> SEEPAGE PIT De rth ' ________Diameter_-_----K.er -__Number . _______ ,4 <br /> P 1 ` i , ' .BIZ '. i - - Rock Filled Yes No <br /> 3 I / <br /> Water Table Depth---r ------- ------ ----------]--------------Rock Size---�--:- -------------------------------- <br /> Distance to nearest: 1NeIL- }--Cr -,-------- Foundation_____. -- -- --- -Prop. Lin6--- ------ --- --- - <br /> REPAIR/ADDITION (Prey. Sanit ti n Permit# -- --- ----- --- if <br /> --------- ---- --- ---D�ate�------ ------ -------`---- ---} <br /> 11 <br /> Septic Tank (Specify Requirements)----- } ----------- ------ - (d a. "�f t - - ----- p <br /> / a <br /> �4 <br /> Disposes! Field [Specify Requirements]............ . ----------{-- <br /> -- -------------`---I------------------------------------ --------------------------------- ------ -------------- <br /> --- - Y <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 r <br /> signature certifies the followin <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 Workman's Compensation- laws of California." CIA�E%%P; _-, S,.rr,;, Jr;,Y_ry 5f ,1I L <br /> s <br /> Signed--- <br /> .- - Owner.., _,.26 So_o,, �.S a ktc�r �a+7# 093205--..--' <br /> .-----------. . _ �.....,,...- �...� . <br /> -- ,.-.� .__ ...Title< Ph:4 u-'.3�G C�n�r�cCc�._ .�� _. ?o.I17?a------- <br /> By---- d" <br /> (If other Than owner) <br /> 1 FOR DEPAJUMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- Q ------------------ ------------------- DATE --------------- - <br /> DIVISIONOF LAND NUM'BER ----------'------------- -------- ---------------------------- ---------------------------------------DATE- ------------------------- -----.---:------ <br /> ADDITIONALCOMMENTS------ ---- -- ------------------ -----------------------•-------------------------------------------------------------------------------------------------- <br /> :, G -------------------- ------------------------------------- <br /> ------------------------------------------------- <br /> -------------- ------- ---------------------------- , <br /> Final Inspection-by-------- - - -=-------------------- ------------------="-------- -------Date T� - -------- <br /> F85 21677 REV.'7/76 3M <br /> i <br /> EH 13 24 SAN JOAQUIN LOCAL-HEALTH DISTRICT <br />