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FOR OFFICE USE: PERMIT FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PE ?� �? aZ <br /> (Complete in Triplicate) Permit No----------------------- <br /> // <br /> ' Date. l ssued.�_'�_`�-._? <br /> •-••-••-••-••-.--------- -.--.- --•------ This Permit Expires I Year From Dgte 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 /> JOB J0 9 83 W A A) 0'C` <br /> DDRESS/LOCATION.... ------—. .. ...... ......:-7--- ----- ............... --- -----.....--..CENSUS TRACT -----:...----• <br /> Owner's Name...-. Q iZeeM Phone... - <br /> - - <br /> ---------------- S 3S ZLc�z <br /> VO- <br /> Address-- --- ►` e1L�t'I om_ (V�a Cit <br /> ` <br /> Contractor's Name-----t,..... --- ---------------- - ..................- License <br /> - -2 -. _ ...-Phone.... - �M <br /> O• <br /> Installation will serve: Residence LK Apartment House ❑ Co-mmercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-.......'. ---------------------- : <br /> Number of living units:.....----.,---__Number of bedrooms--- 'Garbage Grinder:'-::-------Lot Size-----_!!----------- S <br /> ------- ------- - <br /> Water Supply: Public System and name....-- ----------- -------------- ------ ........ ---- ----- -------•--• ------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ['�_J Silt 0 Clay ❑ Peat,E]" Sandy Loam [] Clay Loam ❑ ` <br /> Hardpan E] Adobe E] Fill Material.. -�.-'Ifyes, #YPe j i <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 TANKJ k C�1� <br /> ] ] Size.--`-- �� .� •-- --�--------- -----------Liquid Depth.----•- ----- ---- ---=--- <br /> Capacity- NWO.....- -_T � Material---P�'' <br /> __.Type �--P ----..No. Compa'rtments_._--•----------------------------- <br /> Distance to nearest: Well------ 7-------- --- ..............Foundation....,.b-,. ........4.......Prop. Line.-Si-.---....---.-..----.� <br /> LEACHING LINE [ ] No, of Lines -...-�---_-----..--..- Length of each line .w---------------------- Total Length ... .....-_--:. . �} <br /> 'D' Box..._V....Type Filter Material.---�. fj���-_.Depth Filter Material--.-- -- <br /> Distance#o nearest: Well--....O- QJ-------------Foundation----------------------......Property Line------t........................... <br /> SEEPAGE PIT [ ] Depth_'.'-:'. Diameter..................... -._-- ----------------- Rock Filled_ Yes ❑ No ❑ � <br /> WaterTable,Depth-------------------- ------------ --- ------ ----Rock Size----- - - ------------------ -- ---------- - <br /> t } <br /> Distance to nearest: Well-------------------------------------------Foundation................ ...._._Prop. Line_......._.-_.----_-----. � <br /> REPAIR/ADDITION (Prev, Sanitation Permit#---------------- .......-.Date----------....- -- -------------.- ----- <br /> Septic Tank (Specify Requirements)--t---------------------------------- i <br /> Disposal Field (Specify Requirements)................. --- -. ....................... - ----... ---------• C <br /> ----------- --------- ------------------ ------------------ -- -------- --••-------------------.----------------------- - --------•--------.-.... <br /> '(Draw existing and required addition on reverse side) <br /> I hereby certify that I 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 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 is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed---- �hp <br /> ; <br /> - Owner. GBY % ..._,Title.--- <br /> ........... - --------------- <br /> 4­(If other than owner) <br /> FOR PARTMENT USE ONLY + <br /> APPLICATION ACCEPTED BY..................... ...... --- --------._ .-._ ' <br /> ------------------ ---.-DATE --....... --.f f... ; <br /> DIVISION OF LAND NUMBER................ ........... . --- ------ - ------- ------------------------ - ------- -.D TE...-.. _.- <br /> ADDITIONALCOMMENTS ......... ............ ---- _ -•-----------......--- - --------- ....... ........................- � .-. .. <br /> ,.' <br /> ---------------------- <br /> ----- ------------------------------------- <br /> Final Inspeciion b ----Date------------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT HIS 21,117 RIVO 3M <br />