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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ___________________________________________________ 1 <br /> - (Complete in Triplicate) Permit No.?7._____ _..� <br /> ----------------- `------------------ <br /> ------------------_____.__._.__-.____I-------------_----- This Permit Expires1•1 Year From Date Issued Date Issued -77 <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 /> t CENSUS TRACT---------------- -------- <br /> JOB ADDRESS/LOCATION . ----�-��-:-- ----- � �-- ---�� -------=--- ---- -------- - <br /> . � s <br /> Owner's Name..__, ,r-- � .QtG 'u'`�---------- ------------------------------------ ----------------Phone------------- :--------------- <br /> Address---- ---------- ------lJ 1�'� _ ---------- --- ------- ---_.._Cit!'----- ... -- ---- -ZiP <br /> -_o-�"" �J+ / <br /> Contractor's Name---------` = '•-------- License #--c -_�fS --Phone-T�_7-- _rar.. <br /> {{{ <br /> Installation will serve: Residence EJ. Apartment House.❑ oE]/cmmercial X Trailer Court - k <br /> Ins Motel ❑ I-Other--------CQ- /' i.-C.-C------------- =- f <br /> Number of living units:___0--------Number.of.bedrooms_ ___ Garbage Grinder_ L�t Size----_ -------- -------- _ <br /> Water Supply: Public System and name-.-I ............ - -. = .-.-e:_.---- 2 ----- t _ Private ` <br /> ------ <br /> Character of soil to a depth of 3 feet: Sand - - ---- <br /> F El ! 'Clay ❑ Peat ❑ Sandy Loa ❑,-. Clay Loam ❑ <br /> ' Hardpan ❑ ' Adobe EW Fill,Material_..__,--..__If yes, type_______________________'` •--- <br /> i. <br /> 1 ' r <br /> (Plot plan, showing 'size of lot, location ofa system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> r NEW INSTALLATION:' .(No septic tank 'or seepage.pit permitted if public sewer is available within 200 feet, ` I <br /> PACKAGE REATMENT` [ J' SEPTIC TANK J e_ �( _ _Lam________Liquid Depth.___ _ .___. <br /> 7] _ � /�� �{� <br /> 4 ype. ---- -- -- atenaLi ?u1 �rNo. Compartments---- ----- -------------V' <br /> . . .'Distance to nearest:.Well-__ - � -----------------------Foundation ---- -------------Prop. Line--- .---------------- <br /> ' / <br /> /too <br /> LEACHING LINE; No. of Lines- .--.., --- ------------------Length'-of:`each live__ 4- -----------------Total Length ---�__.__..____----------------- <br /> I 'D' Box OD.i Type Filter Material C "___.Dgpth Filter Material_ _ � _�_________ ___ ____________________'__ <br /> r ; �� ---------- <br /> Distance to nearest: Well------ _______._,k�.F_oundation. _____._-_-------___ Property Line : <br /> SEEPAGE PIT [ Depth ___Diameter---_ �____._N tuber_':_.,____ __ Rock . <br /> [ p 3' p Filled Yesphio <br /> Water To-6IF Depth--------- p--- Rock Size--- 1L-X-^ <br /> [f F1 <br /> Disfanceao nearest:Well'_- --,�-_r�___d__ _______ _ ___�Foundation- ___�' ✓._.__.Prop.-Line-_� ----------------- <br /> ---- <br /> f . <br /> REPAIR/ADDITION (Prev. Sanitation Perm#------ `-------- ---- ------------------ .Date------:------°-:-- :- -------------- <br /> Septic Tank (Specify Requirements) -=-----------V------------- -------­-- -------------- ------ :----------------------------------------------- -------- <br /> Disposal Field (Specify Requirements)-- ----- -.-/..: ------'--------------------------------------------------- -------- ---------- ------------------------------ ----------- ---- <br /> - ----------------- -------------------------------------- --- ---- ------------------------------ .. -------------.-- -- .. ---------------------------------- -- - <br /> i _ <br /> ------------= ---- --------- = ------ = "` - <br /> (Draw existing and required addition on r•`everse sidel r <br /> I hereby certify that I have-prepared this application and that the work�willrbe done in accordance with San •.Joaquin..County <br /> Ordinances,, State Laws, and Rules and Regulations of the San Joaquin Aocal Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for whiih this permit issued, I sFiall not employ-any'person in such manner as <br /> to become.Subject to.-Workman's Compensation .laws of California:'.' <br /> I <br /> Signed-.------°--------------- = - :Owner ^�- <br /> < ... - <br /> BY--------=- ----------------- -------- <br /> -- }r <br /> - --- 1 <br /> Title fin. �•!' <br /> (If other than-owrier) ; <br /> a <br /> -FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-_______------------_ <br /> = ' = --------- ---DATE.------- - arm 7 -------------------- <br /> DIVISION OF LAND NUMBER: ---- I <br /> --- <br /> �7ADDITIONAL COMMENTS-Y 9 N ------ -- --- ------- ----------- -- ---------- ---------------- ------ --------------------------- <br /> --------------------- <br /> -- <br /> -------------- --.-. <br /> -------- ------ --------------=---- - -= - <br /> - � ., <br /> if P . _ - ------------------------- <br /> --------------------------- <br /> -- ----------------------------.- ---- - <br /> Final Inspection by:-' � � ---=-------= --=----- '- ----`=`=-----------------=-----------=�-- Date = �L = '----- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21672 EYZ7/76 inn <br />