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CFi <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT i <br /> --- --------------------- ------- ---- <br /> (Complete in Triplicate} Permit Na..-]._ -./ . --- <br /> -------------------------------- --------------------- p <br /> Date Issued__-2.77A7 ; <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 1z t <br /> Application is hereby made to the San Joaqu.in',Local,Heal'th District for a permit to construct and install the work h rein described. <br /> This application is made in compliance with'County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRE55/LOCATION.__... �] _�'� �. ]] A� n� f�Y l--4--- �lJ-�l�- --CENSUS TRACT-------- - __--_---. <br /> Owner's Name-------- ------ '/ uft",c.C- -9--tr- k1- / L` ------- Phone = <br /> Address. ' = � ` �- -�----- ------- City - ernllX_ -Zip� �� g l <br /> .;- r - •--------=---------- <br /> Contractor's Name____-__ ___- --�y---��-- -:�--�-�+ Apartment House. Commercial al nse # Trailer Covrt___Phone___.__._______�___ _________-,_._. � <br /> Installation will serve: rte Residence ❑ p ❑ ❑ <br /> Motel ❑- Other_Y_7a- itf' pal_. r <br /> Number of living units:-___ _. -Number of bedrooms:__?^`__Garb e Grinder--------___-Lot 5 ------------'x------ <br /> pP Y ' r Y : ��� Silt T Clay -���--���------ - -----------------._------------------Private'❑ <br /> Water 5u I Public System andname_____ ._ _ _D_ -__- -___.__ <br /> Character of soil to d depth of 3 feet. Sand ❑ ❑ y ❑ Peat H-*"Sandy Loam 51e, Clay Loam ❑ <br /> Hardpan ❑ - Adobe❑ Fill Material- ___..__--_If yes, type_____________________... ___--_ g . <br /> t t i <br /> (Plot plan, showing 'size of lot, location of system in relation to wells, buildings, etc."must placed on reverse side.) <br /> NEW INSTALLATION: (No'septic tank or -seepage pit permitted if public sewer is availably within 200 feet,) <br /> f � ] r✓ � <br /> PACKAGE TREATMENT [ ] . SEPTIC TANK [ Size----------------�-------��A ; -----------Liquid Depth.---- 7�----------------�x <br /> CapacitylYZ?O _-_- - yp -Mate�rial__�_�-_�_-�No. Compartments.---��----------- �} <br /> S <br /> 6 � a �- <br /> - istancetolnearest: Well------ ----------------------------- ------Foundation------ =-----------------Prop. Line--------------- ------------ <br /> k. <br /> LEACHING LINE [ No. of Line___- -------------- Length of each line..--- ._Total Length.__../ �4-------_____________ :R,J <br /> f D' Box--!AQ,_-Tybe Filter Material-------I-----------.Depth Filter Material---------------------------------------------- ---------------- <br /> Distance to nearest: Well----- ------Foundation---frr�-------------Property Line__s ------------------------------- <br /> _% <br /> Number_________________ Rock Filled Yes No <br /> SEEPAGE PIT [ ] Depth----- r --Diameter------------------ ------------- ❑ <br /> 1 <br /> Water Tabl�Depth--------- - %I _ R; k 5i e <br /> ----------------------------------------- - <br /> Distance nearest: Well. . ( Foundation--:------------- ------ Prop. Line--------------------------- <br /> i } <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------`--------------" �.''"tjate-------------------------------y--------------- <br /> Septic Tank (Specify Requirement )-------- ---- -- ---------;----- --- --------------------------- ---------------------- --------------- -------------- <br /> Disposal <br /> --------:---Disposal Field (Specify Requirements)------- -------------- -- 1`-------- ----------- --------------------------------------------------------- --------------------------------------- I <br /> t # -------------- <br /> --------- ------ --- -------------------- <br /> C . <br /> --------------------------------- --------------- -- =- -------------•------------------ ------` <br /> # - I ---------------------------------------- <br /> ----- - ------:----- --------=--- --------------------- _ _ . _ <br /> r tl(iDrapplication and thatthe work' willnbevdone'ine) <br /> existing and+ required+ s <br /> I hereby certify that I have preparedr accordance with San Joaquin County jI <br /> of the San Joaquin Local Health District. Home owner or licensed ageints <br /> Ordinances, State Laws; and Rules and Regulation's q . <br /> signature certifies the following: <br /> "I certify that in the performance'aU.'tlie work,for<which this permit is issued, 1 shall not employ any person in such manner as 5 <br /> to beco subject to 1Workm s iCompei�sation laws of California." <br /> Si ned <br /> t <br /> '. B # Title---------------------------- <br /> --------- <br /> (if <br /> ----- - <br /> (If other than owner]' I <br /> rafOR PART EN USE YINLI ` <br /> = fi . <br /> - ATEPLICATION ACCEPTED BY----------- --- - - ---- --- --- --------- D . <br /> - _-.-APDATE- - -- - _._ <br /> ------'- .:- *DIVISION OF LAND NUMBER.-- --- ----------------- ------- - A -- - ----------------- --- ---------------ADDITIONAL COMMENTS = ------- - - --------- ---------------------------------- --- ----------------- <br /> -- ------ <br /> ------------ ------------- ----------------- --------- ----- ------------------- --------------- -- - ---------------------------- <br /> j ------ ----- ------------- <br /> ---------- --- --------------------------- <br /> ----------------------- <br /> - - - - <br /> -- -- --- - - I ----- ---- ----- ------ -------------- ---------------. -- <br /> '-Final-Inspection ect.ion .b i �.- - ----_------_.- _ ------r �-- Date _ _ �` <br /> Aj <br /> EH 13 24 SAN JOAQ)UIN LOCAL-HEAM,DISTRICT Fv,21e77 acv:ane 3M <br />