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c&P• a7 - 71 ] f <br /> FOR OFFICE USE: 7 7` 71� FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------------------- - /5- <br /> [Complete in Triplicate] Permit <br /> ------------ -------------------------------------------- r <br /> '- Date Issued--- 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 and install the work herein described. <br /> This application is made in compliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT ON C.C�i. ------- ySJ--- ------ ---- ------ -CENSUS TRACT-_- .---------- -----------. <br /> Owner's Name. - Phone l�L - 'O��d_ /.----- <br /> --------------------- ------------------- <br /> Address-----/404. . - --- Ci ----------------------- ---- ---- - zip <br /> Contractor's Name---- - ___ License #_ _ �� q Phone �/!s`�G�� <br /> ./ <br /> Installation will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------------------------------------- <br /> Number <br /> ---------------------------- --------- -----Number of living units:-----./--------Number of bedrooms-- ..--.Garbage Grinder------------Lot Size_. __ _.j--- ----0— --.-.___-_.- <br /> Water Supply: Public System and name L..41- -----&A ----------- --Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ r <br /> Hardpan ❑ Adobe 2� Fill Material------------If yes, type----------------------- ------- W <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted V puglliic sewer is available within 200 feet,) 0 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [Jr", Size -- l -S/`--- ---------------------.------------ <br /> Liquid Depth.--�----- ------------ <br /> Ca acit 1-AA.-_-D____-T --_Matorial. ex-e-. -, --No' Compartments-.-.---.--- P _-__I_.__-_ <br /> P Y--- � YP �..��FA L.A�----.- .pC/-+-�-- � <br /> Distance to nearest; Well.-.- ___/('_6--------------------Foundation-... -.0---------.---Prop. Line.-S-- .11f-- --- - <br /> LEACHING LINE No. of Lines--------C�--------- Length of each line--__ __94. _.Total Length ----4V?_74d-----------------_-- <br /> 'D' Box..... -----Type Filter Material S�_ d�k.Depth Filter Material---_l�-„- <br /> t <br /> Distanc&tonearest: Well -_/.-©4--------------Fou ndation--_4pa--------------Property Line-_S---LI !�i.�-----_-. <br /> SEEPAGE PIT [ ] Depth----------------Diameter---------.----------Number______--__-_--_-_-----------.-' Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth---------------------------------------------------------Rock Size-------------------------------- ------------- -- <br /> Distance to nearest: Well---------------------------------------_--Foundation.---------------------.-.Prop, Line_--.__---___-.-.----- --- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date_.____._____._�-________---_---_-_.-,------.-) <br /> SepticTank (Specify Requirements)---------- ---- --------- --------------------------------------------------------- ------------------------------------------------ ------------------- <br /> DisposalField (Specify Requirements)---------------------- - -- ---------------------------------------------------------------------------------------------------------------------- <br /> - - ---------------- ---------------------------•---------------------------------------------- <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 <br /> signature certifies the following: <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 becom _bjeecct to W rkma 's Compensation laws of California." <br /> Signed---- { - --------- � J` -Owner <br /> By- ----------- ---l�--0Title- ----- --------------------------------------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED BY------------------------E.1�---------- ---- ---------------------- ------------------ ----DATE ------ -- -7 rr--- ---------- <br /> DIVISION OF LAND NUMBER. _ _-- ---DA t d-4/0 4,4_ e' <br /> r r <br /> ADDITIONAL COMMENTS.------- - 1� {a ..... r/ > �K L../ - f ----- d - - <br /> ---------- -- <br /> ----- --------------------- - <br /> ------------- --- <br /> Ir h f ms's „C1 4�kl�C y w. f s' <br /> ------------------------------------- --- --,-- - <br /> ---------------------------------------------- -------------------------- ------- <br /> -------- ---- - - - ------ <br /> Final Inspection by:--. ------------Date.-------- ..... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br /> + k <br />