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F R OFFICE USE: FOR OFFICE USE: R ; <br /> �q APPLICATION FOR,AANITATION PERMIT 9� 3� <br /> � �?.. Permit No..- <br /> (Complete in Triplicate) <br /> --------------------------------------------- ----------- % <br /> Date lssued.s- ------ <br /> ........................ # This Permit Expires 1 Year From Date Issued <br /> `2-0 _ 030--� 22 <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to cons�ruct and.in`s�all the work herein described. <br /> This application is made in compliance with County Ordinance No, 54 les and Regulations: <br /> ........ <br /> JOB ADDRESS/LOCATION -- -- K(J[E�(I-- - (CT Y.--. C/�6?2 -/C ENSUS TRACT............. <br /> ----Phone.. , <br /> Owner's Name...... .. . GUgG�-/ G SOi(15................. : 7� ."_�_ .�3. <br /> 11 <br /> Address_:.._ City_ 77 _.. - Zi <br /> f � ISH € So.sIS #._P7fT- "� Z-.. `lb-- ..> <br /> Contractor's Name-- _ .,License <br /> - _. _ <br /> Phone._... . I <br /> IL <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel F-1Other_-1WP�'TV /y----.---------- <br /> Number of living units:_ -:.--.--Number of bedrooms._..........Garbage Grinder--------.-..Lot Size------ _ = � <br /> Water Supply: Public System and name.-I............. . .. - --_-_.Private <br /> tt <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt E] clay E] Peat ❑ Sandy Loam ElClay Loam`` <br /> Hardpan ❑ Adobe ❑ Fill Material.. ___. ....If yes, type............................ <br /> (Plot plan, showing size of lot, location of system in relation-to-wells I5u!Idings;ee c. must be placed-on-reverse-side.y { <br /> S <br /> NEW INSTALLATION: (No septic tank or ;seepage pit-permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size __ .. ..x��----X--`-7- ...__._... .Liquid Depth------------------ ...... <br /> CapacityaD TYPe / G/ MaterialC--._.:No. Compartments..---- - f-`--- <br /> Distance to nearest: Well._;:"�SQ '�' -- Foundation._:._ ' "Prop.L"ine.._. �-. ---- `-- <br /> LEACHING LINE jv]� No, of Lines ........ Total <br /> t Length of each line. ! ------ Length _.. --- .-.- --- --- <br /> 11 <br /> 'D' Box... ..Type Filter Material.__�. � - Depth Filter Material...-- .....�8. ............ :...'..---------- - ; <br /> r / <br /> € s © Property Line. <br /> Distance to nearest: Well---:._..._.�.,_-�--....Faundation._._.�_____ 7�.._-. <br /> 1 _ <br /> SEEPAGE PIT j ] Depth.............. .Diameter-._ --------- --- .Number...------- ------ Rock Filled Yes ❑ No <br /> - Water Table Depth.---------- ------------- ---------....... - ------ ---- Rock Size. -- ------ ---- <br /> --------= <br /> ------------ -- ------- <br /> I <br /> Distance to nearest: Well-- -- --. ----------Foundation.--------- Prop. Line.. <br /> � r 3 1 <br /> REPAIR/ADDITION (Prev. Sanitation Permit ...................... . -• <br /> Septic Tank (Specify Requirements)--:- - - ---- . -----:'•--- -------Y------------- ----- ----------•-- ---.--- ...---- .--..... _.._.. <br /> �r <br /> A { ` <br /> ...__.---_-----"•----••--__-.1 '_.._i................................................ <br /> Disposal Field (Specify Requirements)..............:... .#_.__...."_..............-. ------------ � ! <br /> :... - — � -- .. ------------------------ -------- ------ <br /> ---- ---•--•---------- ....------•--....---- ....... ] <br /> ------- ------------- ..---- = <br /> (Draw existing and required addition on reverse side.)1 <br /> I hereby certify that I 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 Locd) 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_permitjs issued, shall not emplo_y_any person in such manner as <br /> to become sub'ect to Workman's Compensation laws of Califgrnia." <br /> t <br /> Signed---- - .... --- .....-- ... ...... <br /> .._ ----- ------ -- - Tp <br /> B ---•-------- - ------- ----__-....... i le-- <br /> T`t <br /> nea; <br /> Y --------- . .... . <br /> — <br /> (if other than owner) <br /> F R DEP T T USE ONLY <br /> APPLICATION ACCEPTED BY---_... . . . ----- - DATE ....... y .7 <br /> DIVISION OF LAND NUMBER.-- ,- ----.. t....,_.-.-. <br /> ___ DATE.,, -....... . -... <br />' ADDITIONAL COMMENTS..... <br /> -•.... ......... <br /> ---- --------- ---------------- ---- <br /> ' � " . ------ ------ -Date----- <br /> EH <br /> -- <br /> Final Inspecflon b d0Y---- . <br /> ---- - -- -- F&S 21677 REV. 7/94 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />