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FOR CFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR'SANITATION PERMIT 77-s�U <br /> - - - Permit No. - -- <br /> (Complete-in Triplicate) ---- <br /> -- - .. __ ""//7,7 <br /> Date Issued_.._____________ <br /> ------- ---- ------ - - This Permit Expires 1 Year From Date Issued <br /> $ys r•c FGR- /ylG.�i tt LlGvne �P/p�s 77—G /G <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. <br /> his application is made in compliance with County Ordinance No. 549 and existing Rules and <br /> /Regulations: / <br /> �N CENSUS TRACT Q�-- <br /> JOB ADDRESS 'LOCATION __.I/F7� -.._G,-orf�//`'S IC?�P2-__/__�_ . - <br /> Phone S ' <br /> )wner's Name /-_.....--- <br /> -address---------- <br /> SAnz�- -/�-6Qu�--------- ------ --- - city - twte'�cl---------------=--zip_._. <br /> Contractor's Name 1) YleiQ`. - License # /I/esl'1�...-Phone <br /> nstallation will serve: Residence ❑ Apartment House ❑ Corn[nercial ❑ Trailer Court ❑ <br /> Motel ❑ Other___.__ p��� fj� -Q <br /> 'Dumber of living units:_ Number of bedrooms---/------Garbage Grinder/. _..Lot Size._ _ 7 f _ 4clec ' <br /> _Vater 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 /> 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 /> 'ACKAGE TREATMENT [ ] SEPTIC TANK [ j S�e_.__�j � � _ Liquid Depth _ <br /> Capacity 164X) _ _ Type�l-t_G4J - ---.Mate-rialj'_1y1C9C;/ No. Compartments �------- <br /> Z___ -------- <br /> Distance to nearest: Well------ -------------- --- Foundation ._`d'f____;--Prop. Line_-__ <br /> LEACHING LINE:f [,] No. of Lines_.___.__._.____-___ Length jof each line_._ _7 _.-__.. .__-_Total Length._.._ y�_-__-_____________ <br /> i 4t. <br /> 1i <br /> -_/-----T e Filter Materia '' `'4 <br /> 'D' Box <br /> Type IZae,C' -.Depth Filter Material f- f -11 <br /> -Dist ---------------- <br /> Distance <br /> ance to nearest: Well----_--- ------_-_-------Foundation----------------------------Property Line------------------------------------ <br /> S [ ] •%-I!4h----------------Diemvoer-------- --------I4w=.Iaar-------------------------------- Rorik Rillad V ❑ No❑R <br /> Water•-4e--Depth--------------- -----------------------------------------R cyt*�---------------------------------------------- <br /> D. __ - Well .-- --- ---- - -----------------Fes-------------------------- rop. Line--.__,, <br /> REPAIR/ADDITION (Prev. Sanitation Kermit#- Date. ~_ _ ) <br /> ---- ------------------------ -- <br /> +eptic Tank ($pecify Requireme ts)--= _--_ --------------------------------- --;t_v- 1 <br /> ,Disposal Fiefd (Specjfy�equirertts). ------------------- ---------------------------------------- <br /> ---- --- - -- --- ------- --------------------------------------- <br /> r "- a-- •r-- - ------------------------------------------ ---------------==-------- ------------------------------ <br /> ' (Draw existing and required addition on reverse side) <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ..)rdinances, State Laws, and Rules and Regulations of the San Joaquin Local 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 permit is issued, I shall not employ any person in such manner as <br /> .o becor,}e subi t to Workman's Cqmpen t' n laws of California." <br /> Signed - - Ci-��� _ ..-U� ----------Owner <br /> 3Y - ----------Title---- <br /> --- -------------- <br /> (If other than owner) <br /> FO EPARTMENT USE ONLY <br /> \PPLICATION ACCEPTED BY------- - -----------------------------------------------.-DATE.- ------- <br /> 'DIVISION OF LAND NUMBER..--- ---------------------------- ------------•------•---------------------------.DATE.... - --- <br /> ---- --- ------ - ---- --------------- -- --- <br /> ADDITIONALCOMMENTS -------------------------------• ----------------------------------------------- ----------------------------------------------------------------------------------- <br /> ------------------------------------------ --- ----­---------- -----------------------------------------------------------•--•---------•--•------•----------------------------------------------- --------- <br /> -------------------------------------------------------------- - -- - ------- - --------- ------------------------------------------------------------------ <br /> ---- - ---------------------------- <br /> =inal Inspection by:- ----------• --------- - - .>/1----------------------• ----- -- -------_-•--------Date.. <br /> _H 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />