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FOR OFFICE USE: ,/ FOR OFFICE USE: <br /> YYY APPLICATION FOR SANITATION PERMIT <br /> ------------------ <br /> (Complete in Triplicate) Permit No,7 --_7f-__-- <br /> Date Issued_- ..5'.-.:.,2 <br /> -------�-------------'--------------------------....-'-- +s Permit Expires 1 Year From ate Issued <br /> Applic tongohe eby mad to heSo Joaquin Local Health District for a permit to construct and install the work herein escribed. <br /> ,This application is made in compliance with Count E.E <br /> '01 i�nc�No:;549.and existing Rules anct Regulations: <br /> -„ - —S:E corner ofYassorjRoad� & Westeran Pacific -� <br /> t Railroad Co. fTa Calif.JOB ADDRESS/'LOCATEON. ---- ----- . ---- ------ ------ -------.---------•-------•----•-- _CENSUS TRACT <br /> Owner's Name '.______Good_Samaritan Community Services,_ :_�� 209 835--2772,,, <br /> - Y ------------------------Phone-� ) ---- <br /> i P.O. Box 328 __- <br /> Address-----€-------"------- ----- ------=------=----------------------------------- ------------------------------Ci ---- -- �iP -"95376. <br /> �, Tracy <br /> - ,- x , . <br /> Contractor's Name-.GOOd--Samaritan .Comma nity services . Lic se�#_ton-profit phone_........same _____._ <br /> ----- <br /> Instal.lation_will.serve: Residence ❑ Apa`tment' Hou`se.❑ - Commercial ❑ Trailer Court �] <br /> Number of livin# Motel ❑ Other Hosp1tali.ty House for Prison,/. <br /> -H--- - <br /> g units:------b-------Number ofrbedrooms---9------Garbage Grinder----------- LLot''Size�'1; Cxe E - ---------- <br /> 1, i y.f✓�r� rte'.- � .. <br /> Water Supply: Public System and name_---St-�tE?-_Watt ---from-D,V-''I-�`Ix?8I~1tUte Private ❑ } <br /> '� *_-- - ---- <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt.❑—Clay'❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> �..... w—e------------------ <br /> t s { Hardpan ❑ Adobe ❑ FiII 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 eSEPTIC TANK {!C] f Size. ----:r-_ 4+s -- - Liquid Depth �_._ <br /> Cap" ity__.1,-20Q_.___Type_______________________Materidl_--Qn-C.zett`°___.No. Compartments--------2--------------------- <br /> ac �• <br /> Distance to nearest. Well - 1/4 mile Foundation..__ �__?`_-- - _Prop. Line_- 25 <br /> LEACHING•LINEI [ ] No.°of Lines--------2--------------------Length ofeachline z00�_ --..--__-_-_Total Length 200 <br /> 'D' Box..YeS..Type Filter Material '171-i'_`___��Ct3epth Filter Material...._.2_1------------------- ----------- <br /> '-; Distance.to nearest: Well.f 19775---.Foundation-_.-30a _ 25t' <br /> ._ _-________ __ __ --�--- ---------- <br /> SEEPAGE PIT DePrh----_ D.iameter-�------------------Number----------------------------- Rock Filled . Yes ❑; No <br /> Water Table <br /> Depth- Rock Size :- ----------------------- ^I" <br /> --~, Distance to nearest: Well_---- ='-T <br /> _ I ---�- : -----_ Foundation_ _._ -- Prop._ <br /> _ Cine------------- <br /> i <br /> REPAIR/ADDITION (Prev. Sanitation Permit# _______ ------Date .__:__ ._____.______ <br /> Sept!c`TanL(Specify Requirements)-------- - € - ---- -- ---- ------------- ----- ........ ------- ---------------------------- <br /> At <br /> sposal Field (Specify Requirements)--.--.,-:. y------ ------------------------- -------- --------------------- ------------------------------------------------- <br /> -----------------f'----- ------------------- - ----------------------------------- -------------------v <br /> -, I E <br /> --------------- ---------------------:--- <br /> I hereby (Draw existiaddition ng and required aition on reverse side- - <br /> y certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coin _ <br /> Ordinances-State Laws, and Rules and Regulations of the' San Joaquin Ao6a1 Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify,!h:bt`inf the performance of'.the work for which this permit is issued, Vshall not employ any person in such manner as <br /> to become„su.b[ect to Workman's Compensdtion'-laws-of~California.',' <br /> Signed...... oo-d-Samaritan---Community- S vices-----Owner. <br /> B --------- <br /> Oscar �;� ` 1� � Title------"Volunteer ---'------------------- ------------- <br /> If <br /> Y �.. <br /> r {If other ti,a",- ner.. f <br /> FOR DEP RTMENT USE ONLY' <br /> APPLICATION,.ACCEPTED BY', ------------------- -----=DATE #- --7I--------- ---- <br /> DIVISION OF LAND NUMBER. = ' -------=--------- ---------- -------` ---------- -- ------------------------------DATE <br /> ] <br /> r --------- {------- F-�--------- - ,`-------- -------------------------------------------------- --------------------------------- <br /> ADDITIONAL COMMENTS-- - --- ��.,k - - ; 5j 1�-=--F=`-�--I- -`-------'`----`�-�.,,-�"�.-.>_---_'_"_.---_-"'----�'---- ------------------------ <br /> ----- -- ------------------ - <br /> --------------------------`- --------------------�- ----- -------_-=---rte- -✓--------------------------------------------------- --------------- ------------------------------------------------- <br /> - <br /> --- ------------------------------------- <br /> ------------------�'- ---- ------ ------ ----------- - ------------------------------------------ <br /> Inspection <br /> ---------------------------------------- <br /> ---- ` T ` <br /> Date - / ice <br /> Final,Inspection.bY:--_--�-- _ - -_ ---- Z_--. a <br /> r EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT = Fa.s�REV. 7176 Sea <br />