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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FCA SANITATION PERMIT <br /> Permit No- ----------------- <br /> (Cq 4plete in Triplicate) <br /> r_ <br /> - ------------------ -- <br /> ------- Date Issued-------------------- ' <br /> -------------------------- - <br /> ------- <br /> This Permit Expires 1 Year From Date Issued it <br /> ., <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. l <br /> This application is made in compliance witnty O'rdindite 14-ci 49:and.�exfisting Rules an ulations: <br /> hau <br /> CENSUS/1 ---.0 SUS TRA CT----- ------------ <br /> RESS/LOCATION_.- - "/ <br /> Owners i --- ------ ------- -------- - hone <br /> JOB ADDNalfte _ _.- - -------- ------ - -- ------ - �7_,'p <br /> 7�Address.__ 1_ _._ °n C•ty <br /> j ---- -- - <br /> _7 I <br /> Contractor s Name--------�.. #� - $' . . � - -- <br /> License #_ <br /> . . . <br /> Installation will server R si .ence Apartment House. Commercial ❑ Trailer Court ❑ <br /> ' t _ �• Motel ❑ <br /> Other------- -------------- -------' ------- ---.Size - -------- <br /> _- - <br /> Number of living units:__ :._.___Number of bedrooms_____--__.__Garbage Grinder__ i va <br /> ----- <br /> ---- of <br /> I fir , it -Pri to <br /> ----- - <br /> Water supply::Public System and name----=------------=------------ <br /> Character oft i1 to a depth of 3 fest: Sand 0 'Silt El Clay El Peat E] Sandy Loam l:] Clay Loam [ <br /> .._� Hardpan ❑ Adobe❑ Fill Material._. if yes, type <br /> (Plot plan,'showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> i�.. t . <br /> NEW INSTALLATION:' (No septic tank or seepage pit permitted if public sewer is available within 2DD feet,j <br /> t -- - -----Liquid Depth. --t ------------- <br /> Y, <br /> A <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Siz �'-���, � � /� E V' <br />' + s T e --- <br /> capacity-- <br /> r Material. /- - -- . No. Compartments--". ----- <br /> 4 j Capacity-- _A_Re_- Yp, -�-=-- {tF; ` ! _ , <br /> -Pro Line - i <br /> f' d� p <br /> Distance to nearest: Well-'.__._!---9--191-"-=. ----- <br /> l € = - <br /> ..-_Len. �th of each line. Foundation---- -_Total Length �___ ___��-----------------------.� <br /> LEACHING-LINE: . [ 1 No. of.Lines_:___.-- 1--------- g �� <br /> l ------- - <br /> ' - :.-Type Filter Material:._____ ioundation- <br /> epth Filter Material .: - -- --- <br /> i k D' Box__;-� Yp y Lme - <br /> / -- , .) rDistanceto nearest: Well__________ ____'---" -_--- -- Propert ; -- r Filled Ye N <br /> ' 'i --------Numb _ Rock � led s [�• o <br /> t SEEPAGE PIT #[ ] Depth--" -�:----Diameter.__t}_X _ % '1 <br /> ± Water Table Depth--------- 7------------- -.Rock Size---- /J Pr Line <br /> } Foundation_0- <br /> Distarice_to nearest:Well_: _-`-- - < `- - op <br /> - Lam•• - <br /> ( REPAIR/ADDITION (Prev. Sanitation Permit -- ----- - <br /> t <br /> - -" ---- Date ------------- ---------------- --- ---- --) <br /> ------------------------------------------------- <br /> Septic Tank.(Specify-Requirements)----- --------- ------ -------- -------- <br /> i -'- --------------------------- <br /> --------------- ------ ----------- <br /> Disposal Field (Specify Requirements)--------------'-------- -- ---- ---- -------- -"- <br /> t ------------------------------------------------------- <br /> -- , <br /> --- --------- ---------------- ------- ------------ ; <br /> ---- -------- ------------ --- ------=------=--------------------_ <br /> (Draw existing dnd required addition on reverse side) - <br /> th <br /> ance wi <br /> I hereby certify That I havesprepared, this.applicaoaquin CoUn <br /> tion and that the .work �wnllLo aldHealth-Di'st one in pct Home owner orJlicensed agents <br /> Ordinances,. State Laws, and Rules and Regulations of:the: San Joaq <br /> signature certifies the following: ,, : " <br /> "I certify that in the performance-0 f the work for which this permit_is-iss I shall riot employ any person in such manner`as <br /> l �-.'- <br /> to become subject to Workman�s Compensation laws of alifarma. F <br /> t - ----- - _ .. <br /> Signed p°' _ - <br /> $ - <br /> a <br /> ----------------- -- - ------------ <br /> T' <br /> f' � <br /> II'.f of J-tha o raei is I <br /> k ` J I- ��.FOR DEPARTMENT LISE NLY <br /> DATE . --- --- -- F-`✓ <br /> APPLICATION - ----` <br /> - DATE - :: .: <br /> DIVISION OF LAND NUMBER------ .- := ---------------- -- ,--_ - ------------------ <br /> ------------ <br /> ADDITIONAL <br /> ---------------- <br /> - ----- ---- <br /> 4 ADDITIONAL COMMENTS - -------------- - <br /> - <br /> -----------=--------- <br /> ---------- <br /> ----------"------- -- ------------------ -- --- - <br /> ---- <br /> ----------------- ------------------------------------------------ <br /> ------------ . .. - ----- - <br /> --- -fin---- ------r- ------- ------- .---- - --- -.. <br /> Final spection,b - AQUIN <br /> LOC <br /> 8,5 21677 REV. 7/76 3M <br /> EH 13 24 SAN JO OCA HEALTH DISTRICT <br /> yd- - <br />