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1-.- ',e-FOR OFFICE USE: FOR OFFICE USIE' <br /> APPLICATION FOR SANITATION PERMIT <br /> _.....------___--................_.......... <br /> (Complete In Triplicate) Permit No..77.- !i�__3 <br /> ..................................-.................. /3-77 <br /> Date <br /> `j-----------------------------------------_----.___ This Permit Expires 1 Year From Dote Issued I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heroin described- <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: I <br /> JOB ADDRESS/LOCAA-TION.-..........f.'f-�r�._..�p.....����GG/�'��i�....�-A/.CENSUS TRACT..................--....----- <br /> Owner's Name...... 7-..r---------:Fe,* ±__.QI1�.<rK-R5.5_..-.-....--.-.._--•----_-._-----•------_--------Phone--- <br /> Address-------------------- <br /> -Address-------------------- !� M` �-•---•---------------....---•--------------•-----------------...city---A-CF-.Q_.1_--_-- Zip--- ------------------ <br /> Phone <br /> --- ------------- ' <br /> Contractor s Name_........:-•--fe:rScrfl�e�rCt �--------- ----------'-----'----License aP��S +---Ph '11"W_.. <br /> Instailationiwill serve•. Residence I# AApartment House❑ Commercial ❑ Trailer Cant [It <br /> -.Motel ❑ e Other i-----------................-- <br /> G <br /> Number of living units:...L%.....Number of bedrooms � -Garbage Grinder.----------Lot Siu_lat 1r_ .....----­------------ <br /> Water Supply: Public System and name................:...................- ......._.__..._..-----------... ...----.._.......__-......----.-.-.�riwN <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay 9 Peat❑ Sandy LocA ❑ Cloy Loam❑ <br /> • Hardpan ❑ Adobe❑ Fill Material.+.........if yes,type--._........ . <br /> I <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 /> : <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size_......_.... _- Liquid <br /> Capacity_---•-•---__._Type_._ .-.---.-------Material --------------------_.No. Comportments-;._........ <br /> -._._-.•-----•_S <br /> Distance to nearest,well....................................._.:_Foundation__....-.....-------....Prop. One.............-_..... <br /> x,,,it,Et <br /> LEACHING LINE [ 1 No. of Lines---------..............--.Length of each Iine---------,..------.......Total Length---__.L.............._----_-------- 0 <br /> 0 <br /> 'D' Box..._.._.._Type Filter Material....................Depth Filter Material---- -----...--.----.-..-L_..--_------------.. <br /> Distance to nearest: Well...........................Foundation............... -.--------Property Line.�.-.__ .-..-...-� <br /> SEEPAGE PIT ( j Depth--_._.........Diameter................._Number...,.___ _.._... __- Rock Filled Ye`P No❑ <br /> Water Table Depth---`--------------... - - ---._Rack Sim................................1_........._ <br /> _ Distance to nearest: Wall.- ------------------..............._...Foundation Prop. Line----....... <br /> - <br /> REPAIR/ODITIOW(Prev. Sanitation Permit#............ " •'^1-•--•------Dale -- <br /> Septic.Tank'•(Specify Re uirements....._ ._.1.-..-..._............. ...................... ---------------_....__--._--....... <br /> Disposal Field (Specify Requirements)..... 106A-4-d.-- <br /> _ __ <br /> - -------------- -------- <br /> N <br /> �.Y _. .. ..ate y ; _ _ _ _ i--------- <br /> x <br /> ____ _ - . <br /> �Dr x andVkiuired additiom on reverse i ide) <br /> I hereby certify /kat 1 k`ays prepared thls Plica smdY"t the work %-11-be done in accordance with San Joaquin Count <br /> y2 <br /> Ordinances, Stato.ta sus,-end Ru6i and Rjgulatletts[of -the San Joaquin local Health District. Home owner or licensed agents <br /> C <br /> signature certifies the foltowirFg� v 1 <br /> X .'' ; „r r� n <br /> "I certify that in the pedormonci�of th4 work for wMch (s permit is issued, I shall not employ any parson in such manner as <br /> to become subject to mans C_oinp nsation laws4F California." <br /> Signed---- orf.^ -- ............ __.Owner ' <br /> _------- ........ ._.. ..__. _Title..---...-----_---- ................. _..t._-.._... <br /> (If other than owner!' <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ --------------DATE.Is -- -- <br /> DIVISION OF LAND NUMBER......... .......... cr^ - .....w_ —y _....:DATF,,,,,:,�- <br /> ADDIfbNAL'COMMENTS-----^............................-_--_ ................. ----....._ - ...... <br /> + - - - - -- . - _... e <br /> - YC. .._.....-'-----.—...----._•_•-----......--•----...--- <br /> . <br /> Final by, ......--------... 001`.. "in@"OV. -AI a <br /> M to L SAN JOAQUIN LOCAL HEALTH DISTRICT �� r <br /> • s <br />