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FOR OFFICE USE: 119W PI �� FOR OFFICE USE; i <br /> APPLICATION FOR SANITATIO PERMIT 7Jr <br /> ------------ ------------------- Permit No..7.-.-/------ <br /> (Complete in Triplicate) <br /> ---.......-•............... ........... .. <br /> Date Is <br /> sued. "�'`-7-- <br /> This Permit Expires 1 Year From Date Issued <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. 549 and existing Rules and Regulations: y <br /> `J ...... -- S'7_/t'�L.... ---•----- ............ <br /> JOB ADDRESS/LOCATION � � CENSUS TRACT--- --.... -- <br /> G <br /> �L� ALL LLSI" 6. 33. ... <br /> Owner's Name.... . .-.. C� P - <br /> 5`5 = �� .----•-•---- ................ . .... • --------• •--- ----- ----•- --•-------Phone...-- ---- <br /> o <br /> Address- Q� oZ.O . T SI.C.------- ------- --------------- -- ----- --------city....... s� .. ..-- .-- Zi <br /> Contractor's Name....p -----•--___...... -- <br /> . -License #-.RS. �3 3..-Phone....`7:-..- ................... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motes 171 Other.................... --�---��---------- <br /> Number of living units:......�;.YNumber-of-bedrooms--�Z. .Garbage Gr-index-..._._.---Lot-Size---.--.-.-- < x.� Q•----- <br /> Water Supply: Public System and name.s..�-r�i.� �- ------Private ❑ <br /> -..( �'� <br /> E <br /> I <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt E] Clay E] Peat F1Sandy Loam ❑ Clay Loam El <br /> Hardpan ❑ Adobe Fill Material.. ..-. ----if yes, type............ <br /> •-A...-f-,. <br /> (Plot plan, showing size of lot, location of'system in relation to wells, buildings, etc. must be placed on reverse side.) l <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feat,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] -------------- ...Li uid Depth..-:"....- '+L <br /> } Size �-I --- --------- •-----•----•-----•----- --- q <br /> Capacity... Type•------ -- -- - Ma ---terial --- �-No. Compartments--• - ---------- <br /> . ..Prop. Line------ ..-.... <br /> _ Distance to nearesfi: Wel[- -------------`._--;t`...--•"--- ------...Foundation.-.--- ----..----.- -- . <br /> No. of Lines.......... --------- ----- Length'of each:.line---------•---- •---- Total Length . <br /> LEACHING LINE [ ] � ' <br /> 'D' Box...- -.....Type Filter "terial-- -"... ...........Depth Filter Material..----------------- .....41 <br /> Distance to nearest: Well. ------------------ <br /> Foundation--- ------Property Line-------------------- ...----- <br /> SEEPAG --- , <br /> E PIT [ ] Depth.... Diameter '- ---------------Number- ---. ---•--=--------••--- Rock Filled Yes ❑ No❑ <br /> I <br /> -_- ..Rack Size. <br /> Water Table Depth------------------------------ ....--;.- <br /> Distance to nearest: Well---------• ---.........---- ----- -----(Foundatian.......... <br /> L...---. ..... ..Prop. Line-.__- - <br /> - <br /> REPAIR/ADDITION (Prev. Sanitation Permit#. __-.--.S.---,39� <br /> Datet--------��1--'�r-�------- -'-----------1 ' <br /> Septic Tank (Specify Requirements)---- -- -------• •---- -------------------- --- ----- ------------------•=--=--•---- --- ------ <br /> 00, :....... <br /> Disposal Field (Specify Requirements)=. =•-- •• <br /> �3�3 f' ----- <br /> i <br /> -----------N----------------- --------- ------------------------------------------------- <br /> (Draw <br /> ._...- -----(Draw existing and requRed,addition onrreverse side) <br /> I hereby certify that I have prepared this application and that_1Ke 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. Rome owner or licensed agents <br /> signature certifies the following: " <br /> "I certify that in the performance of the 'work for which th�s°permit is issued, 1 shot[�no\remploy any person in such manner <br /> to become subject to Workman's Compensation laws of California." � <br /> Signed - _:.::,.:...--•__---=Owne•r,. .,. <br /> By........ <br /> --- ---------- Title--- ... .577�'L �`1,�+C... <br /> If other than owner) <br /> FQJf'DEPAPfMENT USE ONLY. <br /> APPLICATION ACCEPTED BY----_. DATE . -3- -- - <br /> - - <br /> ----- <br /> DATE..-._. ----•----.... <br /> DIVISION OF LAND NUMBER..........:...: --.- ------------------ <br /> ADDITIONAL COMMENTS. ---------- ---•- ------------------------ •-------------- <br /> --• ---------"------- ---------------------- <br /> --- <br /> -------------------- :-.-.... <br /> ------------------ <br /> -----•-•------------- --- -------- " . -- ---....... <br /> -.-- ..--- - +I <br /> -- - -------- ------- --- -� . . <br /> ..--•-- __ _-_____ __ ..---- � <br /> Final Insp.ectian b Date Z' 9M <br /> --.... <br /> - - -------- <br /> F6S 21677 REV. 7770 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />