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FOR OFFICE USE: FOR OFFICE USE! <br /> APPLICATION FOR SANITATION PERMIT <br /> ] Permit No..-.7f-- <br /> (Complete <br /> ----------- (Complete in Triplicate) <br /> 1 Date lssuecl d�---2/7 <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. t <br /> This application is made in compliance with County Ordi once No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION_,.,_ _S ___ 4�- ----------- ----I1-- �J,�ILs --- (------------:---_-.,.._._.CENSUS TRACT--- <br /> -J�► ..._V - ---------------- + ----- <br /> Owner's Name.'__ Phone-_,306,F_-- is <br /> Address------------;-fll -; ' ---- ---- City---.-- ( Q ------- ---- ---zip--- 5 <br /> Contractor's Name-_ _ --- ---;-1 JIL - +'- --------- -------License #---(3©_5__D ___-_Phone._36s__J�__ <br /> Installation will serve: Residence ®Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> i q-Motef-0—Gther =-- = <br /> Number of living units_________ ------Number,of.,bedrooms;--3_s_--'1Garbage.Grinder-------------Lot;Size___.__�_(D aC2 -- _._._----,------ --- <br /> r � � , `✓gyp � . <br /> ---- <br /> Water Supply: Public System and name:.. -�------- r------------------- - --------- -------------------------- -Private [� <br /> Character of soil to a depth of 3 feet: : Sand "Silt Cla l <br /> P ❑ �] y ❑ '� Peat Sand Loam [4,-"'Clay Loam- <br /> _, ❑ _ Y ..� ._ �� Y ❑ <br /> Hardpan ❑ Adobe.❑ FiII Mafe(%gl_-__.'_-_.__If yes, type--_:-------- <br /> ____ <br /> ------' -------- 7 <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 se tic tarik'or, see a e it erm'itted if ublic sewer is available within 200 feet, <br /> P P g p P P } , <br /> PACKAGE TREATMENT [ ] ; SEPTIC TANK _ ----------------------------------- <br /> [.1. Size - -�.-r-- .� _'.Liquid Depth--------------------- <br /> IleF .. -Capacity-----------'`-_----TYPe------------'----------Material----=- -- ' '' <br /> t ------------N6. iompa;tments-Cr- ---- <br /> Distance.to nearest:Well ------- <br /> ---------------Foundation------ ----- ------I1-Prop Lmfti_ - ) <br /> LEACHING LINE. [ ] No. of Lines-._____.______ _ Length,of each line.__-__-____________-__-_ ___.Total. Length - __-----______-_ <br /> -------- <br /> t <br /> 'D' Box---------, -Type Filter Material--------------------Depth Filter Material---------�--------------rr------------------------_- --, , <br /> Distance,to nearest: Well---------- -- -------- --Foundation-________________ <br /> pertyyLine-------- --------------------------- <br /> { ----__-.Pro � .. <br /> SEEPAGE PIT Num be.�... ___ Rock Filled Yes E] No ❑ <br /> Depth <br /> Water Table,Depth <br /> meter---------------J-- -----`-�---------�---�-R.ock Size-------------------- <br /> Disfance to nearest: Well Y' .:.Fo ndation -` Prop. Line.: <br /> i <br /> REPAIR/ADDITION [Prev. Sanitation Permit'#--"_:__:F -__:___-_._:_ __ Dat-_.._'_--- '_________________ I <br /> l , <br /> Septic Tank.(Specify'Requirements)_ _ s r '` ' <br /> - <br /> --- - --- --- <br /> Disposal Field (Specify Requirements)--------41�5_� .Ae Xle --[ --- -- ' -- <br /> A ---- ------- --- -- --f-� <br /> - --------- ! s _ <br /> - - ----- - ------ -------------------- ----------- <br /> ---------] f; a s [Draw existing and required addition on reverse side) ± <br /> 36, <br /> hereby certify that I have repared-this-applicption--and-�that-thewvork-*ill -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 perm is issued, I shell not employ any person in such manner€as <br /> to become subject to Work an's Co ensation laws of California." <br /> Signed-=-------- ------------ - ----- -------- - - -- --- Owner <br /> I. <br /> 1­1 <br /> c.�.v - _ <br /> BY r------:- - - Title_ - -" - <br /> I (lf ofher'thari owner) { i <br /> t - F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ,_r -- -=-------------------- ------------------ ----------------------------- DATE.:. . -- . p_� + <br /> -- <br /> - <br /> DIVISION OF LAND NUMBER. ----------------=------------------------------------------- ------ DATE ---------------------•- <br /> ADDITIONAL COMMENTS------------=-------------------------------- <br /> ------------------------------------------------- ------------- -- <br /> .i <br /> --------------------------=---------------- - <br /> ------------------------------ - --------- -------- r i <br /> ---------- ---------- ------ -------------------- ...... <br /> ---- ------------------ ------------------------------------------------ - <br /> Final Inspection by:---- .- ------------------------------ ------- -----------------pate. � ' <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&s 21677 REV. 7/76 3M <br />