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R OFFICE USE t� IC r .. FOR OFFICE USE <br /> fes° <br /> ATION FOR SANITATION PERMIT <br /> ' (Complete in Triplicate) -- Permit <br /> .............................. . ...... <br /> h` Date Issued.`?`�....,1.-. 77 <br /> ...... ........... . ....... --------- ....... This Permit Expires 1 Year From Date Issued• _ <br /> .atidn is hereby made to the San Joaquin Local Health District for a permit to co�l''isiructt7nd Install the work in described. <br /> hcation is made 'n c rap ,an ith unty ,nonc 549 and-ext;t' g ules a d Regytat. - <br /> %DDRESS/LOCATION _ CENSUS TiRAC[ <br /> is Name. _.�I�.. .-/ .w T :-- - Phone d _ �✓�,.,' . <br /> :55... -. {_ �.� , Y .:� t--� ,j�/: C' -` .a--�_: �.Gty...... <br /> actors Name.:. ! `.-t.�- Zlt/4�/N�l:'.1 ' '�!J"'t`= f i+cens f ay n r..:4'. <br /> lotion will serve. Residence Apartment House[]� Cornmerciol- Tra,le [ ; <br /> r MbteL❑ <br /> .e of living units. Numberlofbedrooms ' Garbage;Grir er ..i• t.Slz' cc� . ... . <br /> Supply: Public System and name Private ❑ <br /> .der of soil to a depth of 3 feet Sand ❑ - Silt❑ Clay❑ Peau $ani Loam Clay Loam4 t i <br /> Hardpan E] . Adobe E] . :Fall Material ...If yei type--:1 T. f t W <br /> dari, showing size,of lot, location of system in relation to wells buildings .etc. usl be'piaced ori reverse side. - <br /> INSTALLATION: (No'septic tank':or seepage pit perrnitted if public ;ewer is m vailable`w:fh200 feet <br /> AGE TREATMENT [ ] SEPTIC TANJC --- s / .... .......:Lqu+d Depth -' t <br /> Capacity,3+ ;Type..- :�t.No!. Compartments _ �.- q <br /> Distancetone//aarrlist Wellj��'. ._,. ,.v.. .Found_gt�on . �0��. .._Prop Line7� - <br /> TING LINE i No. of Lines `'' i1�A'jenotHfo each line �'�,1�` o total Length ;1 .1;,. �f {# <br /> d <br /> { <br /> D' Box I <br /> ¢ Type F+IT Mgibnol (L{ Dep(h'lfilter Material f d -- _ f , <br /> Distance to nearest Well /.rr1 ¢ , Foundation ,t LSA) Property tine +�� .- <br /> - t <br /> GE PIT [ ] De1:a er y Humbert Rock Filled Yes ElNo;Q <br /> LWatet Table Depth Y f ( .. t�fe✓ - - .. — {I <br /> Distanc*to nearest Well^..-+ <br /> R/ADDITION (Priv. Sanitation Permit$ ---------- <br /> Tank (Specify Requirements]-`!'' :;:I. .. ,. .- .. . . . .. <br /> sal Field (Specify Requirements)_,_; .,. _ <br /> _ . .. . a <br /> ----------- - -----------.. ... . . - ( - <br /> (Draw existing and required addition on reverie side) ¢j _ <br /> 3y certify that I have prepared this application and that the :work will bit*d" in accordance with San !Joaquin Coufrty <br /> races, State Laws, and Rules and Regulations of the' San Joaqulh1o;6l Health District. Home owner or licensed agents <br /> urecertifies the following. (( <br /> ify that in the performance of;thb work for,which this permit islssged I#hllC t employ any penonldsuch mannerlas <br /> :ome subject to Workman s ..Ction' laws of California. <br /> iompensa " <br /> ! f <br /> I r r, f :sy Oweler ' l <br /> .. .. .;• / Title. � .t' e i 1. .' 1 <br /> - (If other than'owrirl) - ` -" <br /> s FOR.DEPARTMENT USE ONLY "' r <br /> :ATION ACCEPTED BY4. 77. <br /> ON OF LAND NUMBER _. r ' x ' DATE _. _. <br /> IONAL COMMENTS <br /> - <br /> nspection by:. .. e - Date f._. <br /> SQA JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV, 7n6 aM <br />