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rOR OFFICE USE: 7 � FOR OFFICE USE: <br /> ~ APPLICATION FOR SANITATION PERMIT <br /> [Complete in Triplicate) Permit No,--- j_- <br /> - __3y <br /> --------------------- ---------- ------------ - <br /> Date Issued_._S`�o._.7.. <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 andinstallthe work herein described. <br /> This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> JOB AQDRESS/LOCATION-------------- <br /> -- ---- !,�! - � � Lr _ . -�. _ - - <br /> r 5 # ; US ZRACT <br /> Owner's Name 1.�. ..Lys_ T t------------ --------------------- -----------------Phone-------- <br /> Address ;, ('l .��� l p 74� L .- Zip <br /> Contractors Name � -lam"> --- - "may- {�`cE #+:.�` Phone------------------------------ <br /> Installation will.,serve: Residence W Apartment House C] Commercial ❑ T iilr Gourt. ❑ <br /> i t Motel ❑ Other -- '---- -"- ---- <br /> 4 a f <br /> Nu,mbe of living units:.._...' ----Number'of bedrooms:_.f"� -Garbe e Grinder - Lot Size `� �'_:-........ �... <br /> _ t--,--- ---�� ---- i <br /> Water Supply: Public System'and name,_:.;: -------------- ------------ - - - -- --- --------`----------- g- -Private <br /> Character of soil to a depth of 3 feet:., Sand ❑ Silt© Clay ❑ Peat Q Sandy Loam ❑ Clay Loam, <br /> Hardpan ❑ Adobe.0 Fill:5Material----------.-If yes, type-------------------------------- <br /> (Plot plan, showing size of lot, location of system in relc5tion to wells, buildings, etc. must be placed on reverse side.) ' j <br /> NEW INSTALLATION: ` ,(No "septic tank :or seepage pit permitted if'�public sewer is available within 200 feet,) <br /> PAC KAbE TREATMENT SEP71C''TANK ' °?- ¢ �" i_ } - �•-- ' <br /> { ] f�}_ _ ,. _Size:-—�� #-. '.Liquid Depth.-61. <br /> ' '-- <br /> trialT <br /> ol <br /> C�mpartments ' <br /> .Capacity/ <br /> __I <br /> i <br /> -----�-- <br /> -- <br /> Distance`tot.rearest: Well__- -- - - ---------- ---- Foundation 0-- ---- ---Prop: Line..----- <br /> AC-I � length - cine - Total- - ---- -- o '------- <br /> --------��er Material ..aD' Box___I___:: YPe Filter Material:-/� lDe t "...." <br /> ------- <br /> 4 --------------- <br /> Distance <br /> __--Distance to nearest: Well �+ -.-.----.t­Foun�lation..- ----..........Property Line...... ►� <br /> -- <br /> �i <br /> -... <br /> SEEPAGE PIT [ ] --- er---`-------°._..' Rock Filled Yes ❑ No ❑ <br /> Depth. ___.Diameter y=__ f <br /> Water Tab)e Depth---=------- ------- -- - - f"- --- -.Rock Size' <br /> Distance to riearesf:Well---- --------_------�. ! -- --.Foundation :-----:''----- -----'--.P" '- ---_ <br /> �. ,rop. Line-- -- - -------- <br /> REPAIR!ADDITION (Prey: Sanitation Permit#_ _____ _ ___ -------- - ----------Date------- - --------..---------------KI___) �' ] <br /> Septic T nk [Specify.Requirements] ------------- --------------------------------------------==----.-----}�-------------- -----------------I <br /> Disposal field {Specify Requirements}_ i # ------------------- <br /> ------------ <br /> ------ ------ <br /> =_ --------------- - --- <br /> --- <br /> �-"Oruaw`existing a d requiredjladditio\on reverse side)L i <br /> I hereby certify that I have prepared this application and that thew rc'� Abe done in accordance with-San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations �oF the Ser Jdaquii cal Health District. Home owner or licensed agents <br /> signature certeifies thfollowing: s <br /> "I certify that in the performance of the work for which'ihis'permit is issued, I shall not employ any person in such manner as <br /> to becolme sub' ct trorkm s Cam en anon laws .of California." .. <br /> s ! 411 <br /> Signed - g - <br /> By-=------= , - --- ------------------------------ ---------- ------ <br /> ( an owner) IA t <br /> If other th ` ' <br /> FO DEPARTMENT USE O LY- i' 1 <br /> APPL6TION ACCEPTED BY.:..: <br /> DATE.-- ----�----"-= <br /> ' = <br /> DIVISION OF LAND NUMBER...- ----- • _ -=--.DATE-;---------------------- <br /> ADDITIONAL COMMENTS - -=--t-----------=-------- -- ;' -------------------------=-------------- ------=---------- - ------------------------------- <br /> ----------------- --- ------------------- ----------------- - - `� ------- --=--- --------------- ----------------------------------------------- <br /> ----- ----- ------ --------- -- - =--=-----'---------- --- ---- --------- --- -�. - ----------------- ------- --- ---- ----------- - ------ --- <br /> 1Inspection by.-' . ..-----------------Dat -------- <br /> EH <br /> - ----EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f&5 21677 REV. 7/76 3M <br />