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• �•I � � � �FOR O�IC USE: <br /> � R OFFICE USE:. O� ` <br /> APPLICATION FOR SANITATION PERMITc� « �-��3 <br /> -------- -----. _ --Permit No- ---------- - <br /> (Complete in Triplicate) <br />-� -------------------------------------------------- - �7 <br /> Date Issued__3� �� � <br /> _------ <br /> ------ -------------­- This Permit Expires 1 Year From Hate Issued <br /> 8 <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:, a _� <br /> ,JOB ADDRESS/LOCATION �_ CENSUS TRACT .._ _. .__ <br /> Phone- <br /> --------------------------------------- <br /> C, <br /> one <br /> Owner's Name- L'. _s^"l�----------1-W��,j------- -------- -= --- <br /> �. G r-, �_074w <br /> Address------ -0 �--/v-�A`nr/2-----4-.!?AW--------------- - --------City ZiP <br /> Contractor's Name.V_ (llC ._ �..1�.--- $ --- ---------License #a93_3 -----Phone_ a7" 7"Qj"_.". <br /> 6-5 <br /> Installation will serve: /� Residence ® . Apartment House F­1Commerciale❑ Trailer Court ❑ <br /> Motel ❑ Other =------------ <br /> /.� I 3 9 _ 0...L Size------ ------- ------ <br /> Number of living uni ___..__ <br /> 1 � \ _ umber of bedrooms________.__Garba a Grinder___ Lot, -"Private <br /> Water Supply- Pu lilt System-and nam_e.--- ��-- ---- ------------------------------------- <br /> Character <br /> ----------------- ❑ <br /> i <br /> Character of soil to a depth of 3 feet: : Sand ®^ Silt❑ Clay ❑ Peat❑ Sandy Loam (] 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 /> NEW INSTALLATION: (No septic tank-or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK, [ }' # i Size--��_V_p 6-'"a'�- `� ' Liquid Depth---- -------------------� J <br /> capacity J� X ao Type Materials I4 -----No. Compartments---------�--------------------- <br /> (�„ <br /> ,Distance to nearest:.Well.---:- Od_ T------=- - . Foundation--------------------------Prop. Line------------------------- <br /> .3 __ <br /> .Length of each line.- --- <br /> - ---.__.Total Length _�/o-��--_-------- <br /> LEACHING LIN_ E' [ ] No. of Lines._._ _.._,,,._ <br /> rp' Box -! ----"Type Filter MateDepth Filter Material____ ���_� - <br /> Distance to nearest: WeIL__/4 47___________ __Foundation_.____ _:_---_.__...Property Line------------------------- -----"--- <br /> SEEPAGE PIT. ['] Depth_ _.-_____.._Diameter., <br /> ---;__--Number-_�--------------------"_---' - <br /> Rock Filled Yes ❑ No E] ' <br /> Water Table Depth----------- -- ---",--------=--------------------- Rock SizeY-:_. - <br /> Distance.to nearest; Well--------------------------------"cam- :--Foundation_" "___________________ __Prop. Line..____-_."__.__._.,------ <br /> -i I <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----:-- ---- -----------------" .Date--=:-----------------------------------.------1 <br /> Septic Tank (Specify Requirements)-----' ----- -- - �'---- --------.'J,k* --------------- --------.------------- <br /> ------- <br /> ------------------------------ ff <br /> Disposal Field (Specify Requirements)------ ----------- ;-----------.._------------------------ ----- I <br /> ! - - --•------- � { ---- <br /> - --- - - - -- ---------- ------ ------------ --------- ----- ------ --------. ---- <br />[ <br /> --------------------- -----=-- -------; ---(Draw existing and required addition ori reverse side] <br /> N. <br /> I hereby certify that I have prepared this application and that the work will 'be done 1n accordance with San Joaquin County <br /> Ordinances, State Laws; and Rules and Regulations of the Son"Joaquin Local;Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> „ <br /> "I certify that in the performance of'the work for which'fhis permit is issued, -1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> { <br /> Signed---- - - ------------------------- ------- -- -- --------- ----- --.---- ----- wn <br /> Ar <br /> BY --- Title - ; <br /> [If other thanowner) <br /> ( F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTER BY = D <br /> C ----------=` ' <br /> --------- <br /> DIVISION OF LAND NUM,BER -------=-----i=--- -------------------------------- -------------------------------------DATE ---- _ ---- <br /> DATE <br /> i ADDITIONAL COMMENTS-----= ---- - --- ------------ _:-.-------- ------------=_. <br /> ----------------------------- <br /> ---- - <br /> -------=-------- - - - -- --------- -----------------------+u' <br /> �J c <br /> Final Inspection bY- ' 4 ___."�_ ;� ------------ ----- - Date_ Z -l.- ----------- <br /> ------------------------------------ <br /> .__j i. . <br /> Ery 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT gas 2ia�� Rev. �i�e 3M 4 <br />