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FOR OFFICE USE: FOR OFFICE USE: <br /> �r • APPLICATION F42m; SANIXATION PERMIT <br /> - ------ ----------- -------------•--- -- - 1 . Permit No.._74."�-� <br /> .= r _ (Complete in Triplicate) _ �. <br /> ----------------------- - --------------------------..----- ,. <br /> Date Issued.-.7`^p?.�".."7�` <br /> ------------------------------_ ----------------------- This Permit Expires 1 Year From Date Issued <br /> c <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 /> _ 9 <br /> JOB ADDRESS/LOCATIdN........2_-�.: y6� V--A._".. I�0,V----- - ": . ------------ -------CENSUS TRACT-------------------------------- <br /> k. <br /> Owner's Name ------------- �---1-------------- - ---,-=------ -------- ° <br /> -----------Phone------------------------ <br /> Address------------'----- ----510>1W19,--- ------- ----_- � -----------------------------------------City ----'�'-,�o`Y------------------------dip <br /> 1. ... <br /> Contractor's 00ek----------------------- #.A?4`57-9'G------Phone__6..Z3'y__2_i" :"... <br /> Instal lation�wilI- serve: Residence ❑_f Apartment House❑ Commercial ❑ Trailer Court 0 - <br /> . - - -------- <br /> .__...t. ...,p--• .�.".Motel�•❑- �.Other-�---l�ls2_�_iL- He,N+�... <br /> Number of living units:__`_--1""_____Number.of bedrobms-�"�.---Garbage Grinder-__________Lot Size-----_ -o.- f�c_rs------_._ <br /> Water Supply: Public System andname _ :------------ _ _ Private El---- <br /> Character of soil to a depth of 3 feet: : Sand X -Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ `Adobe-E] Fill Material--.-- ----If yes, type <br /> y , ------------------------ ------ <br /> 5 <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 if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT--[ ] SEPTIC TANK [ ] Size-------- -;------=`- 'A/vk_""-- Liquid Depth-'------- ----------------- <br /> e�9 "' Compartments-,-- <br /> :-..-- ------------- = <br /> Distance to nearest:.Well:_---- /A-67'­k---Mated..-..---.-Foundation <br /> al - Foundation------- Part ".Prop. Line-;lsa *-----.-----" <br /> LEACHING LINE ['l No. of Lines----- --- ---'---- length of each line------- a:�-.-_.- Total Length ...r_IlG - ------------ -------' - <br /> D' BOX------------ Filter Material (7 .. Depth Filter Material, :::: -',----------------------------------- <br /> 0!,c . <br /> I � . 4 ao t <br /> Distance to nearest: Well '. /" 6 -------- __-.Foundation -/-----------------------Property Line._ _ --------------------- <br /> ---------------- <br /> ---- -_ <br /> SEEPAGE P17 [ ] Depth__._.___".""". "Diameter.:-.___;_.__.""""."Number--- ________________________ Rock Filled Yes ❑ No <br /> pt --�'[-----------------Rock Size--------------'- ----------- <br /> ` Distance:to nearest: Well --------------^- - - ------------:---- --- <br /> Water Table th.""_-.____: <br /> ' ----------------- -.------ ---- ---- .Foundation-------- -- -----. .Prop Line-------------------- - <br /> REPAIR/ADDITION (Prev. Sanitation-Permit#----------__-:.. y <br /> -------- -- --- ---�----.Date-- - � - - ------------------------- ----1 r <br /> Septic Tank (Specify Requirements)_.,- ----- ------------------------------ <br /> - "-- --- ---------------- <br /> Disposal Field (Specify.Requirements)-----s -- --- ------------------------------- <br /> ----------- -- <br /> - - ---------- ----- ----------- -- --- <br /> _- - <br /> -- ---- ----------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that-11 have prepared this application.and that'the=work will be done in accordance withSan-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 /> "1 certify that in the performcince-cif`the work for which this permit is issued, 1 shall not employ any person insuchmanner#as <br /> to become subject to Workman's .Compensation laws of .California.',' � - <br /> Signed h-"-i-1_9-�1'- Q1Y. d�Y ----" :Owner . <br /> ---- ----- --- ---- = Title <br /> t,. <br /> er t wner) }.. ` <br /> ( FOR D OARTMIENT USE ONLY ; <br /> ". . <br /> APPLICATION ACCEPTED-BY"".:_ _. ---_---- �'�- ------, ' - ------DAT i = = : - <br /> DIVISION OF LAND NUMBER.;--------- -- ----------- --- ------------=------------==------------ ------- DATE.:---.-- = = " <br /> ADDITIONAL COMMENTS------------------- -------- -- ------=----- ------ -'-- ------ ---- --------- ------------------------------------------ ------------------------ <br /> ----------------------------- --------= =4------------------- ------------------ <br /> E ---------------------------------_---_---_-------------__------"----------_------_----._-_-_-.- <br /> i �.. I <br /> ------------------------------------- -------- --- ---- -------------------------------'----------------- <br /> --------------- -----I---------------- - - --- ------------------------------------------ <br /> C <br /> - --------------- <br /> "_" ------ ----- <br /> Final Inspetion by:"" - ------- ------ '�. _ - .Date.- <br /> EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />