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FOR OFFICE USE: _ / FOR OFFICE USE: <br /> V PPLICATION FOR SANITATION PERMIT ..r <br /> 76.0 <br /> --------- ------ ---- -----_ _ -- <br /> ..._ -- - <br /> --- . <br /> (Complete in Triplicate) Permit No..7ff---1 <br /> -------------------- ---------......-..-- --------- <br /> Date Issued..- -.2-.7.- <br /> _-_ -------- -----I....... .._------------------ This Permit Expires 1 Year From Date Issued <br /> %pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> s application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> IOB ADDRESS/LOCATION- -5 e �2... -" {'�^_ <br /> R('L� CENSUS TRACT - -- <br /> (� <br /> rner's Name .-. �ll -- _. t. - -(]--�._.... .. ..._._--- ------------ ------- -------------- - Phone 1 a.... <br /> c <br /> '.dress.. .. ..gt-t2- - �P City---- --c_fo e- `C'lV ZiP <br /> License #. . o �S�r'. Phone- <br /> yM�,� <br /> Contractor's Name--.1V� ` '� - - .�� .L. .... .. ._ - <br /> tallation will serve: Residence Apartment House( Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other....... . --_ ------------ --- ----- / <br /> \1,lmber of living units:......f------Number of bedrooms_ Garbage Grinder...&IO.Lot Size-----t-,P(n X �' --- -- <br /> i`)ter Supply: Public System and name-- ------------ ------ - -----.... . . ..... -. ----------------------------- ------------- ------- ---- --------.Private <br /> 2haracter 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 /> �Tot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> "r-W INSTALLATION: (No septic tank or seepage pit permitted if�public� sewer available within 200 feet,) f a <br /> 1_,CKAGE TREATMENT [ ] SEPTIC TANK { Size ._.�.. .� -------------- __-.___. -- Liquid Depth.--662- --------- <br /> Capacity-./6& <br /> .-_.---- <br /> Capacity-./6&_Ce� TlltMfaterial_ -. /P `fNo. Compartments___..- <br /> - - <br /> YP <br /> Distance to nearest: Weil---------- /. ___ ---- ---------Foundation.- Prop. Line..X/VV_-_-----_.-� <br /> LTACHING LINE [ ] No. of Lines ..... - ------------- Length of each line. 0 Total Length _ -f <br /> D' Box Type Filter Material--- c:2- epth Filter Material...-- �---_ ------------------------- ------ -------------------- <br /> 2 <br /> --------- ------ <br /> / 21_57.r 0 <br /> _ Distance to nearest. Well-_--/1 _Q-___-.- Foundation- -_---------_Property Line..._-.�--_.._-- <br /> SEEPAGE PIT Depth R eter_..-__- u _-------- ---------------- ; . Rock Filled Yes ❑ No❑ <br /> ✓✓✓,��` <br /> -2-y/dX is Water Table Depth------------------ --------- --------- ------- Rock Size._1..1 ..-_... ... - ----•----- <br /> Distance to nearest: Well-__.-. ................................_.Foundation---------------- .. ......Prop. Line----------.----.--...._ <br /> PrPAIR/ADDITION (Prev. Sanitation Permit#-------- _- - -- ---------------Date_------------.-.._------- -- .._ ---------) <br /> `ptic Tank (Specify Requirements)- ---- -- <br /> Disposal Field (Specify Requirements)................ ... <br /> --------------------- -------------------------- -------------------­----- -- --_---------------------- <br /> ------------- ---------- -_---------- ... ..... ....................... ------------------------------------------------ --- ------ -.. .--- -------------------------- -----......... <br /> -------------------- ---------- - -- ------------.... ..--- ----------------.----------------.-------------------------------- ------------------ ----- ----- -- ------- ----------------- ------------ <br /> (Draw existing and required addition on reverse side) <br /> ,iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> 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 /> °re become subject to Workman's Compensation laws of California." <br /> Signed........... --- --- ------------------ ---- ----- ----- --Owner <br /> y. 1.- 11- ----- Title-- <br /> _ - - - <br /> (If other than owner) <br /> g FOR DEPARTMENT USE_ ONLY <br /> -nPPLICATION ACCEPTED B - � y r_ :, r��f -.._.. --- ----- --- ------ DATE <br /> .. . <br /> DIVISION OF LAND NUMBER.-- . -- ............. ---------•-- .DATE ----- - .......... -------- - <br /> ,DDITIONAL COMMENTS_._------- -------- . <br /> -------------- ---- -- . --_ -- . ----- ------------------------- - -_- --------------------- ------------------ -- ---- ------------- --- -- -- --- -- <br /> --------------------- <br /> ------------------- ---- ---------- ......... --- - - ------ ­- --- --- ------------ --- -- --- .. ... .... <br /> ------------------------------------------ - ---- ._.. .. . ----------- <br /> ...---- ----- -------------- ------------------ -- ------------------ ---------- - -- <br /> lnal Inspection by:. �S ' - ----------- ----- - - <br /> Date.�.f.- .- <br /> EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M <br />