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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ' it No.��-" <br /> -----------•---------------- (Complete in Triplicate}� Perm -�' --`'f��-- <br /> ------------------------- <br /> e <br /> ------------- Date Issued_ _5_ -- <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: rt <br /> JOB ADDRESS/LOCATION -< U � 4-----�>-P----. ------ ---.._.CENSUS TRACT--------=--- <br /> Owner"s Name.--- ---- ---�-�: -.�, .. ,- <br /> 16 --- ------- Phone__ . <br /> E ; -- Zip <br /> Address. --- .--- -- ------ ----- - ---- -- ---- --- --- --�-•---- � <br /> ity <br /> Contractors Name--' -i� l-Qr�' ---------- --- ------ License #o�� <br /> 7t Ph -�� <br /> 0 <br /> Installation will serve: Residence�] Apartment House ❑ Commercial ❑ Trailer Court ❑ [ <br /> t •._.,_�.. ;. Motel El +'Other _ ! 1 <br /> - <br /> It <br /> Number of living units:_ .-__-1__ Number of bedrooms- Garbage Grinder.� ___ _Loi S.izsw:- __ -- -.-- <br /> 1 1--Private <br /> _----------- <br /> y <br /> _. __.__ _ ______ __ __________._A.•...._.__ __ <br /> I <br /> ❑ Y [�i; Y P e <br /> Water Supply:.Public,System`and name----_ ------------------ � <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ }Clay ❑ ' Peat Sbnd Loam Clay Loam ❑ <br /> Hard an Adobe Fill Mate <br /> P ❑ . � ❑ ria(-------------If yes, NP?------- ------- <br /> [Plot p;an, showing size of lot, location ofisystem in relation to wells, buildings, etc. must be placejd on:reverse side.] <br /> ermined if ublic sewer is available within 2:00 feet,) , <br /> 4 NEW INSTALLATION: (No.-septic tank r seepage pit p R <br /> PACK;:'GE TREA„MENT [ ] . SEPTIC TANK [.] Size- <br /> ... <br /> ize - ------- -----=------------- ----------- iquid Depth ' ---- <br /> Mate,Tial--------------------------No. Compartments_ --------•-•----------------------- <br /> Capacity G <br /> I F <br /> :-:_- TYPe `.------ <br /> } Distance`.to nearest: Well- .---- ---Foundation-.:_,__.' -.._--=--Prop. Line------- -------------- ---�' <br /> --------- <br /> r - <br /> 1 --------- ---- - Length of each line------------------ ---- -= Total Length,,---------------------z- = - <br /> LEACH�IiVG LINE, [:] No. of Lines._ ____ - g <br /> D' Box---- ------ pe Filter Material -------------------Depth Filter Material-----------------:------------ --------------------- ' <br /> Distance to nearest: Well----------------------------Foundation-- ----------------.Property Line------------------------------- <br /> _7k <br /> ---- ----- -y <br /> r u._ _... ._ Rock F11I Y N <br /> SEEPAGE PIT j ] Depth---`-----------Diameter- ------=------' Number--- ------- - --- �----: ed "Yes <br /> ❑ o ❑ <br /> nce to nearest: WeII__.. Rock Size=------------=-- <br /> t Water TableDe th___`- <br /> Dista --- -------------- ------------- ------foundation--= Prop. Line <br /> REPAIR/ADDITION (Prev:Sanitation Permit#"3_�=--`- - -=- --------- l----- <br /> ------------------- -_ Date'.-_ i <br /> Septic Tank (Specify Requirements)--------= --=: A----------------------------------- ---------=---------- - , <br /> f <br /> I <br /> _ • v *- <br /> ----------------------- <br /> Disposal -}i <br /> -- <br /> Field. RequirementsM--�___ ------= -- -�--- - --:-�---- -- ------------- <br /> ---------- <br /> -- ----- <br /> ' <br /> ( - _ . . � . <br /> - +;= - ------- --- -.-.-- <br /> ------------ -- ---- - - <br /> -------------•---- -------- --- =---- ---------------------- -�-,- ---- {- ------ <br /> ---------- =- - ---- <br /> ---- - -- ---- t -- 'required addition"onasidefv6[Draw-existr1g-and- r <br /> hereby certify that I have preparecl�thils application and tharthe work will--be done in accordance with San Joaquin-,County <br /> Ordinances, State Laws; and Rules and Regulations of-tlie,�Son Joaquin Local Health Dist_rict.,Momeowner or licensed genas <br /> signature certifies the following: <br /> 111 certify that in the performance of'.the ;work f�whichthis-,permit-islissued, 1 shall not:emplay any person in such, manner as <br /> P i California. I, ! <br /> Owner F <br /> to become subject to or an s ompensah -�--laws <br /> cif-��- .-- � t,. ^-• - _• - - <br /> '$u <br /> Signed--------.e�' ; <br /> I -------- -�1 fii le ------------------ <br /> By ----- -------- ------ ----a-- --� --- a.r`�5 <br /> t <br /> ---------- ----�--- w: a1 <br /> E ;[If�oYher than lowrier) <br /> 'FOR pARTMENT USE- <br /> D <br /> ; ------------- <br /> . . ' t c r 1------------- <br /> -----DATE <br /> PTD'BGPLICATIONAPACCEEXi ------- <br /> DIVISION OF LAND NUMBER _ --------------------- ---- -- --- ---------- - - DATE . ..._... ± <br /> r U�.Er - t � _ .._ - <br /> ADDITIONAL COMMENTS_-___ <br /> ----- ------ -------- --------------------------------------- ----------------------------- <br /> --------------------------- <br /> --- - ------------------------ ------------- <br /> --------------------------- <br /> z - <br /> = -- - , <br /> >e <br /> -- ------ ---------- <br /> ------------------------ - <br /> I .. ; ------------------------------------- --------------------- <br /> -------- f� <br /> ---- ` = 7 <br /> - -- -- --- -- <br /> x <br /> Final'Inspection -._Date------ ---�J�- -------------------- <br /> ----------- P Y:-----_- ------ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />