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—•�:.��-ter--�-- <br /> .�'� {, <br /> IN6,1 <br /> FOR OFFICE USE; FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------- <br /> (Complete in Triplicate) Permit No.;7l`K -.__. <br /> Date Issued_3"-.-�1-/-'_. <br /> ------------------------------- ---------------------- -- This Per Expires 1 Year Frorn-Mate,lssued <br /> Application is hereby made to the San Joaquin Locall 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/LOCATI ^ G?' - -------/...'. A...i -- --L ----- -------------------------------CENSUS TRACT- �` " <br /> . <br /> Owner's Name. ?_.. ---------------------------- --------------------------------- Phone---�5���.2_ <br /> � <br /> ty. <br /> Address X� . : Ci Zip <br /> Contractor's Name.---- _- --- --._- - License #- 2?l----Phone_c <br /> Installation will serve: Residence Apartment House-E Commercial ❑ Trailer Court ❑ <br /> Motel ❑. Other---- ------------ - - - ------=---------- <br /> Number <br /> --- - -Number of living units:.-. ------...Number of bedrooi�s.-.�1'.- -__Garbage Grinde.r___- /Lot Size-._. � _a <br /> Water Supply: Public System and name---------------------i---- ------------------------------------------------------ -------------------------- --Private <br /> Character of soil to a depth of 3 feet: . Sand ❑ Si`It❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ <br /> Hardpan E] Adobe ❑ _ Fill Material-.------ If yes, type-.. ________________ - <br /> 0 <br /> (Plot plan, showing size of lot, location of system inrelation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION:' (No septic tank or seepage pit per if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT [ I 'SEPTIC TANK j�}�'r' Size_____4x---sx d��LI�_-------.Liquid Depth... 45__ �__-.. 04- <br /> I <br /> Capacity-1164V-------TYPe-- '-------Material e101V_-- --------No. Compartments-------�?,---------- �f <br /> Distance to nearest: Well---_!_ -. . ...-_ . Foundation.. l-------- ----Prop, Line.,,;700 <br /> or <br /> ----------Total Length ---- i----- .- <br /> LEACHING LINE [a�No. of Lines-_.......-��.._.________ -..Length of each line_.-_._ _ � g �__-- _____ <br /> D' Box.. -_T e Filter Material_/I,/_�� De th Filter <br /> ;. Yp. , . . p Material ; -------------------------- <br /> Distance .- .. <br /> i / x/�- ���----- -----Founda 'on-----------------------------PropertyLine-- --,t�-/------------- <br /> 1 . . x- - . '^r/ <br /> IT ['� Depth f ------ <br /> --- Br�e�r.. ./� <br /> to nearest: We _._ _ <br /> - ----------Number---------------�----:-_-�--'q Rock Filled '-Yes No (� <br /> .�/� pry. ✓ ,a` <br /> a Water Tdble Depth----- i�---------------- ------------------------.Rock Size---/---------------- -----' t <br /> ,cam <br /> Distarice.to nearest: Well---..,J/_t- :.i_' -Foundation- / �)l_ � <br /> ------ Prop. Line ------ <br /> ADDITION [Prey. Sanitation Permits# 'I�----=-=---1-------- ---------- -------Date----------------I-------------------- y � \ � <br /> REPPAIR/ I` <br /> Septic Tank (Specify Requirements)------ .I __--_------ '----____�i_____- k <br /> --- <br /> Disposal Field:(Specify Requirements) A-- ----- ----- ------------------------------- "-------- — --------------- ------------- -- <br /> ------------`=---- -- --------------------------- <br /> '•------------- I -- _ �� yr t <br /> Imo. `[Draw existing and required adtion on reverse side) � Ki <br /> t /, 1 --� <br /> I hereby certify4hat I`havelpreparecl this,application and that the work will be done in accordance wA" San' Joaquin C <br /> Ordinances, StatekLbws;'=�Acl Rules and\Regulations) of the San Jo'�tnquin Local Health Districtx.Home�pwner:. or licensed age <br /> signature certifies the following: \ _ 4 '„$ <br /> "1 certify that in the p ormance of'the workfor hich this permit is issued f shall not employany person in such) manner ds <br /> to become subject to Work n's Compensa#eon laws-of-California,” <br /> 4 V. <br /> 4�- .�.,�.�_, '��.v--""--.. � <br /> Signed--------------- - �11 = - Owner <br /> 4 <br /> BY------- --- . - ---- ------------------- - =---- --_ Title p4Jr•------- Vy C-- - ---- -- ---------- <br /> 4 <br /> (If other than owner) <br /> 'FOR-DEPARTMENT USE ONLY' " �'�"x° � .r•-�/�f <br /> i. <br /> APPLICATION ACCEPTED BY DATE. <br /> DIVISION OF LAND NUMBER-------=---------- --- - ------ --- -M --- -------------- <br /> ADDITIONAL <br /> ----ADDITIONAL COMMENTS ------------------ ---------------------------`'----- ---- ------------------`--- <br /> ------------------------- --------------- ----- --- --------------- ---------------�---------= - ------------------ <br /> ----- ---------------------------------- ---------------------------------------------- <br /> f <br /> Final Inspection b f- -✓. Date...- --:---- <br /> --------------------------------------- -- <br /> "''3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 Rev. 7/76 3M <br />