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Cl FOR_J0FFICE_4JSE: FOR OFFICE MSE: AF <br /> - ----"-'.!� ` �r-�-----------"-" - APPLICATION plOte SANITATION ripicae} PERMIT Permit No-- �7-^FF <br /> L -- 3- <br /> Date Issued <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: + <br /> .S -.CENSUS._TRACT---=--- _------ <br /> JOB ADDRESS/LOCATION ...__..__(. _ ----.___v.'�"'�-• - 31___ __. f <br /> Owner's Name------------------- GC-�.. : �- ----- ---------- -..---Phone-----E:---- ------- <br /> AddreAddress <br /> ss ------277-s-Z----- -- - -------- -.12-- I-----t`'`--- ---- City--------- ------- ----------------------Zip----------------------- ------- <br /> - <br /> Contractor's Name........._-_._ -- - lt? ____._-- #_A5_- _ ....._._Phone_ � ___ ��.______._. <br /> InstaIIation.wiII serve: Residence E]' Apartment House ❑ 'Commercial ❑ Trailer Court, ❑ , <br /> Number a 4 <br /> /Motel ❑ Other--------------------------- --- --- -=------- <br /> [ <br /> f living units:___._.�_:_____Numbe'r of bedrooms-__7��Garbage Grinder, .:.___.Lot-Size___.____/__.._.. -c { <br /> a ! - ------------------ ------ � + <br /> -- LT" <br /> it t depth of 3 feet: Sand -...Silt "--�.."Cla"""."�"".--Peau --".--""Sand -"Loam ----"-."Cla-""Loam"------""-"-------- <br /> Wat <br />{ P ❑ ❑ Clay Peat ❑ Y ❑ Y ❑ <br /> Chaeactepof sopa to <br /> System and name______________ Private <br /> I Hardpan ❑ Adobe 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 TANK [ ] Size--------------------------------------------------- -"-----Liquid Depth-------------------------'---- <br /> - "`_Capa`city#Tgpe------ --- Material .------ o; Compartments ---- ----- - - <br /> Distance to.nearest: Well.:- __ _.___Foundtion._ _______________ Prop. Line ---- -- <br /> LEACHING LINE [ .] Na. of Li'nes --------- . Length of each lines. Total Length.:. - + <br /> D Box ---.----Type Filter Material Depth Filter Material---------------------------------------- 4---- <br /> r Distance to nearest: Well-----------------------_.....Foundation-----. -----------= p y <br /> Pro ert Line <br /> jSEEPAGE PIT [ ] Depth __.Diameter_.:_ , Number____ ---- ±__, Rock Filled Yes ❑•-~•-No- <br /> .1 Cir i. ---------------------------- <br /> -Found <br /> , <br /> Water Table Depth.__:_ _-- --____-- '--------'------.Rock Size_'---------------- _-1' <br /> f Distance to.nearest:Well--------------' . ___ Foundtition '._- Prop, Line________________.____ ____ <br /> .. <br /> REPAIR/ADDITION-(Prev.:S_anitation•Permit#_._.__:____ -:__ _ Date -------------------------- <br /> Septic <br /> _.___ " _ } "^'+ <br /> Septic Tank (Specify Requirements)-- . : �.JJJJ:.. 3'� _ - - '" ` ' t'� ;i <"``� <br /> Disposal Field (Specify Requirements) Y r'P/4`mac' -------------------------------------------- <br /> ______________________________________ _____ __ --_______ _ ____ -------------------------------- _.______--__ <br /> w. <br /> -------------------------- ----------------- - ------------ ---- -; ' ..------- <br /> .• (Draw•existing and required addition on reverse side) <br />[ I hereby certify that l have prepared this application and that'the work Wilir be done in accordance-with San Joaq' uinl 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 /> "I certify that in the performance of the work•for which this"permit isissuea;'I sha-II not—employ_—any person in such manner as <br />+ to become subject to Workman's. Compensdtion- laws of California.'.' a a <br /> Signed--- ------------------------------------ <br /> ----- <br /> -------- ------- ------- -----Owner <br /> BY-:------- --------- -- " 1 Title <br /> i ' <br /> ( oth'e'r than'.owner) _ }; _s .. __ 3 i <br /> FOR DEPARTMENT-USE-ONL-Y <br /> APPLICATION ACCEPTED. BY ___ <br /> DATE._. 2 7 7 . <br /> DIVISION OF LAND N.UM:BER., _- -- - ---:-_;. ------------------------DATE :------- ----------------------- <br /> ADDITIONAL COMMENTS----- -------- - ------ -- ----------- ----- - ---------------- --------- <br /> ------=-------------------------------------- ' - ----------------------------------------------- ---- -----------------------------M-----------------­-------------- - ---- ---------" <br /> . V 1 <br /> X <br /> R _____________--------------- <br /> --------- <br /> _______________�_,_ ---------------------------- <br /> ------------------------- <br /> Final Inspectionrby::_._-_�j�.. r Date --~A-5 �2 %_ <br /> -- ---- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677,RM 7176 sen <br />