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k `FOR OFFICE USE: 16.- FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ' <br /> ! --'------- . .. .....----.................. (Completi' n Triplicate) Permit No.�y------ -------- <br /> •� ] i Date Issued-[e'(.6. 9....... <br /> ............ This Permit Ekoies 1'YeaPFroin Date Issued <br /> Application is hereby made to the San Joaquin Local Health Disfri8 for a permit to construct and install the work herein described. <br /> This application is made in compliance with CountyiOrdinance,No.N9 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION w .Z :_Q _ CENSUS TRACT------------------. <br /> Owner's Name o4 d..--._. . +.-....... ::Phone.--- <br /> Address . - .F-bl.�. CitY1 � 1'-41.Q "' .... . ...Yip c' .......... . . <br /> Contractor's Name .. .~License_�.�2"'3 �-----L�- - �-�I <br /> Installation will Ap <br /> serve: r Residence�,' �' a .Q7 im <br /> nvent HousiComercial -Trailer Court ❑ ' <br /> Motel.-El- Other...:..:--- ...- ----�--- _3_?:... ,..... ; <br /> INumber of living units:./ t.....Number of bedrooms;,9 Garbage Grininder J`t.(2�. ---F--- ------------ <br /> Water Supply: Public System and name .......................` , ' . # ;.... . ,-.,-: - .. .Private - <br /> Character of soil to a depth of 3 feet: Sand ❑ `Silt❑ Clay❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> " ` fiord'�dn� " Adobe � Fill Ma}erial-----.-.....If yes e..-',...Tib': .:.._..: <br /> I P ❑ ❑ Y iy ; i <br /> )Plot plan, showing siie'Of lot, location of system in relation to wells, build ings,;eic.'must belplace'd,on reverse side-) %N <br /> PACKAGE TREATMENT 11"],(N se tic tank or seepage pit'permitted'if public seer is available wii}iiri 200 feet,) J <br /> SEPTICTAi�1K_[ ] Size...........----_---------------------wr _Liquid Depth.- <br /> ------ <br /> epth - (h <br /> NEW INSTALLATION: ` P, ' y� ' S C , <br /> .Material . ----------------------[No. Compartments- <br /> [ <br /> Distance nearest Well `mow� .Foundation?> _3_._ Prop je� ... .. r <br /> LEACHING LINE: [ ]' No. of Linesno \ f ea\�" li a Tot"I- Lengti ... <br /> i I `D' Box--------:..Type Filter Material . p Filter Material' i. .- _ .� . <br /> '! r"-_"r•"_'^"�" ,r._. '`:7� «_ ... . --- -- <br /> vv� ] <br /> • + DistanceTa'n2arest: Well -t Foundation �/ ' „ - Pi`operty Line..,.... <br /> -. _.., 1 <br /> SEEPAGE PIT ) ] i Depth.._.,__- ...Diameter.'._..t__ Number ,�/ Rock Filled Yes ❑ No(� <br /> 1 Water Table.`1[Dept-h._ _-:) ..__ ..Rock'Si ..'L ,r �X... ... .. , <br /> Distance�to nearesi:'Welh�'?} �....:.t7.F,ou`nda'tion: ,, €'! �.lPrdp, Line.. .. . -..__ <br /> REPAIR/ADDITION (Prev. <br /> -----:...:........"""'itation Permit-#------ ...:........ ...`.....r... <br /> n <br /> ----------- ...........Tank 1 PicifY. 4uirrements). ' - -Ata5)_ 1.:,f ', <br /> Disposal Field Sea Requirements)-----------Exisli' Jt.-. <br /> r <br /> .. -. . cr .'..: Q .: .............. <br /> '7t� 7,, rd <br /> .....L -------- <br /> 7 �,-cam <br /> > _. equite . <br /> . (Diaw existing and requued a"dditibn,� revise side) � - <br /> I hereby certify,that 1.�"ave prepared this application-and that the-work will be~done in aante with San Joaquin County <br /> .. Laws <br /> Ordinances,-) Laws, and Rules and Regulalion3 of'.the, San Joaquin Local Hea fhtrDi;trick 7foRiieL6wner`or licensed agents <br /> signature certifies the following: • J a 2 t� <br /> I "I'certify that in the performance'of the woik for which this permit is issued, I 'shell not empl, y any person in such manner as <br /> to become subject !a Wjo/rkinan''s'Comp�ensation laws of California." _ ] t <br /> Signed--- - T''' y% lCs" Owner ; � �s . <br /> By.!.......: ......... Title <br /> :...... .... [ ..' .-[?:Q'ec--- `:---.._ -- .....- <br /> -'---'�..-`fJ 3'?- --t % -.pl•':..:...... :....... <br /> r f other }ban' <br /> owner) - FOR DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED`BY.,--............. .. .. ..............:. - !-----...::.:..... ...:'- - ---.t..DATE _.... ---- ---- '--'- <br /> DIVISION OF LAND NUMBER,------- `---- --------`--------------------------`-----`----=------------ ------------ ---DATE ----------------------------- -- - ------ <br /> ADDITIONAL COMMENTS------- --------'-------------'--- -'-"----------------------------------------- -- <br /> ----t-------------------- - - - -- ........ -.-"-...-------------------- ...."'........... .........-"--""---------------- ---:........ <br /> ------------ --------- ....;. - ----:-_ --'--- <br /> r�oFinal Inspection-by:'-.'-_--'- - .» .-.•'r..•....^..:.......---------'-------Date..b.���l.-�.:C-.�C--""-'.............. <br /> nl 13 sa SAN JOAQ IN LOCAL HEALTH DISTRICT F 6" REV.7176 3M <br />