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Amok <br />FOR OFFICE USE. PPLICATION FOR SANITATION PERM f <br />............... . ................... 41 (Complete in Triplicate) t <br />.................................... ­­ ................. <br />......................................................... This Permit Expires 1 Year From Date Issued <br />FOR OFFICE USE: <br />Permit No.;.-,.�vp--- <br />Date Issued ... 2 e <br />Application is hereby made to -the San Joaquin Local Health District for a permit to construct and install the work herein described. <br />This application is made in compliance with County Ordinance No. 5119 and existing Rules and Regulations: <br />CENSUS TRACT ................................ <br />JOB ADDRESS/LOC TI N....... .. . .... 1-1 ....... —1 . ......................... <br />Owner's Name. .... .... 11111 1111111111 ll',/ <br />P411111? <br />111 11 � <br />............................................... ......... . ................... Phone ............................. ........ <br />AddressJy3_47 _,,446% _&.%,& ............. .................... City. Akc ................... ZAP---,: ------------- <br />--- License <br />Contractor's Name --../T,6,4 ..... V Phone.. AAW .... <br />........................ <br />Installation will serve: Residence E] Apartment House_Commercial ❑ Trailer Court n <br />Motel E] Other-.. <br />Number.of livingunits::..-_. ----- Number of bedrooms.....,... Garbage Grinder ............ Lot Size..Z�.... �.. ........ ......... <br />WaterSupply: Public System and name ................................................. ................................................................................. Private <br />Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay ❑ Peat f-1 Sandy Loom E] Clay Loam F1 <br />Hardpan E] Adobe X 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 />PACKAGE TREATMENT SEPTIC TANKP................... Liquid Depth .... .................. <br />Capacity.1-A0.4 ..... Type 6.tMaterial...O e ... 2 ----- <br />-,e ...... No. Compartments ........ a . .. ..... <br />11 <br />Distance to nearest: Well..,/04 ..." <br />..... :�__ ........... .... Foundation.. ...........Prop- Line... ...-------- <br />/LEACHING LINE No. of Lines ..--/ ....................Length of each line_/6_0 .............. Total Length __6.."................... <br />'D' Box ............ Type Filter Material _Zt._ P*Depth Filter Material ......... /d ...................... ............. ........ <br />� <br />Distance to nearest: Well ... 14A... - ....._.Foundation._. 47.0 .................. Property <br />Line .................. <br />---- <br />SEEPAGE PIT Depth..;?..S ..... Diameter...,?.4. ....... Number ........ / .................... Rock Filled -1 No F <br />4 <br />Water Table Depth .......... /0.6 ......................... ........... Rock Size-----%.�C„........................... <br />Distance to nearest: Well ..... ..... y ................ Foundation ---- .....Prop. Line..-.' ...... <br />REPAIR/ADDITION (Prev. Sanitation Permit# ...... ------------- .......... ............... Date ......................... .................... <br />Septic Tank (Specify Requirements) ......... ................................... I .................... ................ <br />Disposal Field (Specify Requirements)--_............................................. ... .................... <br />........................................................ ­­­ .......................................... ­ ............................ <br />............ I ........................................................................ <br />(Draw existing and required addition on reverse side) <br />I hereby certify thatI 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 ofthl- Son Joaquin Local Health District. Home owner or licensed agents <br />signature cerfifies 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 />to becomegiec, to 3yorkmag . s compensation laws of California." <br />r....... ........ Owner 4/7 ............................................ <br />. .................. <br />Signed.. ..... <br />By ......... <br />Title ................................. <br />03 <br />(If other than owner) <br />APPLICATION ACCEPTED BY ..........�� ....... t4 <br />DIVISION OF LAND NUMBER ................ <br />AD.D),TIONAL COMMENTS_ <br />........................ . ..... I ............................................. <br />DrOPARTMRNT V9 ONLY <br />T_ ......................... ..DATE <br />. <br />-....... DATE <br />---------------- ­* ------------ ---- -- #1 ........... <br />............................. ­� ................. t .. 1, <br />...... M------------------- <br />........... 7 ................................ <br />................................ <br />----------------------------------- ----------------- .................. <br />............................................. ------- : -------------------------- --------------------------------------------------------- ...... . ...... <br />--- .............................................. Date... 7. -j -- -- --- -------- <br />Final Inspection by:. --- E IL:. I <br />------------•------------------------ .. ----------- - --- --- <br />F&S 21677 REV. 7/76 3M <br />EH 13''24 SAN JOAQ elLZI. HEALTH DISTRICT <br />