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, FOR OFFICE USE FOR OFFICE USE: ; <br /> APPLICATION FOR SANITATION PERMIT In <br /> >=----------------------------------:----------- Permit No.,�q_ -- <br /> i (Complete in Triplicate) <br /> bate Issued-?-__.------ <br /> ----------------------- ----------------------------___.__ This Permit Expires 1 Year From Date Issued y <br /> Application is herebyAva—de 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 /> -1 <br /> egulations: <br /> JOB ADDRESSAOCAilO_hl :: �- --------�------t CENSUS TRAC _l. <br /> : ' j"t .ma x /�, /1 � - ---------- ---- ---- ... Phone- --- ;I <br /> Owners Name_ : `- r <br /> : <br /> Address------- ---- <br /> t4 <br /> . <br /> Contractor's Narh-e:....... =-% `�- -_------------'V_1 e<,)67 '- ......License hone.. = <br /> s f Residence []t Apartment House. Commercial Trailer Court D <br /> -� = <br /> Installationwillrve: t Motel,0 `Other___. <br /> _ <br /> tuber of living g wnnits:_,__--��(�TNumbeerr cotb drooms.�_�-.Garbage GrindE+r____________Lot�Size_____ "7 :: -- ---- <br /> Nu <br /> Water Su I u lic 5�+s }- t � <br /> PP Y Pb y tem and name`'.;. - ` /:..'j - Private>4 <br /> r ,� <br /> Character of.so t to a depth of.3 fee Serid Sil#'QCiay E] Peat F-1SandyLoam ❑ Clay Loam <br /> C Hardpan 0 IAd'obe 17,1"' Fill Material-------------if yes, type--------------------_ i <br /> (Plot plan, showing s ze�f fot� �o" tioj. <br /> n,of�system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No-sept tank'or seepage pit permitted if public sewer is available within'200 feet,) <br /> PACKAGE TREATMENT [ ].-,..SEPTIC TANK [ ] SiZ6-------------------------- ------------------- Liquid Depth ---------------------` N <br /> GapacitY -- ------------Type-= ----------------__.Material----.-------= =-----__No: Compartments J <br /> w Dista ce14o nearest: Well-- -------------- ----------=---=---------Foundation------4 ------------Prop. Line-------- -------- ------ <br /> LEACHING LINE [ ] No:af'Lines_-_" __.-___.____.___..Length of Each line. _________________Total Length ---____-_----------------------________ <br /> �„ }. ,r f/ <br /> D' Bax---- -Type Filter Material ;_!__C)�' ep;h Filter Material------- ------------------------------------------ <br /> Y>Distan6e to nearest: Well___ - ___.Foundation 1 ____. Property Line -__ <br /> j,, <br /> SEEPAGE PIT [ ] Doth.-��._Diometer� -_`__Number______ -ZV---_------------------- Rock Filled Yes ] No ❑ <br /> WaterTable Depth----_-----------------------------------------------------Rock Size----- l--------------------------------- <br /> _Foundation.-- ---_ L� Prop. Line.------ <br /> -f - + <br /> �. 'Distance to..nearest; Well---- ---------/'.�-,--�------=--------- - � - � - ----- <br /> REPAI DDITIO ev:Sanitation"Perini..ti------------------ Date----------------------------------------------) <br /> Sep"tic Tank (Specify Requirements)---- "--------------- --------------------- <br /> -:---- -- -- ------------------- <br /> --------------------------------------- x <br /> Disposal Field (Specify R�erits)--.-------__ _ ---_ >� __-� � ✓ ' <br /> ------------- - <br /> ______________________________________________ _ __________________ _____ _________ ________________________________________________________________________________________________________________ <br /> f -- -' - - <br /> g <br /> (Draw existing and required addition on reverse side) y <br /> 1I•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, Horne owner or licensed agents <br /> signature certifies the following: <br /> I <br /> "I certify that intihe ,performance of the work for which this permit it issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation,laws of California." <br /> yc - i M <br /> Signed - v s -----:Owner c - <br /> BY-:----- �✓� !�( `J `` f� l� = Title <br /> [If ther thon. wner) . <br /> FOR DEPARTMENT'LISE ONLY <br /> APPLICATION ACCEPTED BY- -- . <br /> ---------- - --- DATE ------------------------ <br /> DIVISION OF LAND NUMBER-------=-------- -- ------- --------:..-----------------------------------lam:---- '_.DATE _µ <br /> _ . - <br /> ADDITIONALCOMMENTS------------------------------------- - -- ---------------------- - -------=-----------------------------------------------=------------------- <br /> ` =- ----- ---------- ------- ------------ -----------=------------------------ - --------------------------------------- -------------------------- - <br /> `--------------------=------------------------ ------------------------------ ----- `------------------------------------------------------------ ----------------------------- --------------------- <br /> --------------------------- --- -- .+ ----------------------------------------------------.-------------------------- - ------------------------ <br /> 2___Final Inspection "� - ------Date----- ----'�1----- <br /> FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />