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FOR OFFICE USE: _ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �" <br /> Permit No..-7�-- <br /> -------------------------------------------------------- (Complete in Triplicate) <br /> - - <br /> -------------------------------------------------- <br /> ---- Date Issued._3�'r'�� <br /> This Permit Expires 1 Year From Date Issued <br /> Applicdtion is hereby made to the San <br /> This application is made in compliance with CountJoaquin Local Health District for a permit to construct and install the work herein described. 1 <br /> y Ordinance No. 549and existing Rules and Reg�uldtions: l <br /> JOB ADDR7 SS/LOCATION ----t-- - :. /_ _ -- ` F=" = CENSUS-TRACT------------------------------ <br /> ------ -- <br /> Owner's Name_ Z - phone <br /> it3_U - le� - <br /> -Zip----------- ----------- <br /> AcIdress - ,J <br /> } License # ' ' 2-Phone <br /> Contractor s Name__.-._ i- -- ----� � -' <br /> i <br /> Installation will; serve: Residence (�° Apartment House ❑ Commercial ❑ Trailer Court. ❑ <br /> } I Motel ❑ <br /> t i / ---- Lof <br /> Size--mms-_-.Garbage Grinder- <br /> Number. <br /> of.living nits--= = -----Nu - lX- <br /> , <br /> - - Private <br /> Water Supply: Public Systemand name-_------- --------------E_---------- -- ------------------. <br /> Character of soil to a depth of 3 feet: Sand ❑ -Silt Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam 0 <br /> � � <br /> Hardpan Adobe❑ Fill Material----- ----If yes, type--------------------------- <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) i a f <br /> a TION: (Noysepti" p p public sewer is available within 200 fe ,j _ � <br /> NEW INSTALLATION: � c tank -or see age pit ermitted'if ubli Q� <br /> � -- '4� ------ <br /> -SEPTIC <br /> PACKAGE TREATMENT [ ] 'l Size-_-- _- - Liquid Depth.____---_ <br /> 4 TANK '[ _ No. Com artments_ ---__o� - ; <br /> ------------------ <br /> t <br /> Capacity./- --- YP al = p .r <br /> T e - L /-.Materi Prop. -Line--- ----------- - - <br /> Distance to nearest: Well_ -- - --Foundation- <br /> Foundation-XV <br /> ACHING LINES [ ] No. of Lines...__-_.,;,- Length of each fine_''-�� -------_-_--' --:Total length__-,���__---,_------------------ <br /> LEACHING <br /> --------- ----- <br /> Depth Filter Material--- -- - J/--=- -- --------------------- <br /> t 'D' Box.--(--------Type Filter Material_//.�1� - P , r <br /> � `Distance.to nearest. WeIL/��-- . -------------Foundation_-/0----------------- Propert R Line. _ ------------N <br /> �.e � ~ <br /> SEEPAGE PIT [ ] -------------- Y <br /> Depth.��..�.�__--Diameter.- __�-__---__-Number__.-___�-- . <br /> „ � <br /> N <br /> _ _ Filled es <br /> r `•1 --------- <br /> Water Table Depth- - Rock Size- t- <br /> Distance' nearest: Well.' r <br /> { = Foundation---- ---= ?:Prop. Lint <br /> k <br /> . ------:Date---:-------=------� "- :-- -------- <br /> REPAIR/ADQITION (Prev. Sanitation.Permit-#------------------------- ----- <br /> Septic Tank (Specify Requirements)------I := ----=-------- ------ -----=------------- ---------------------- ----- - <br /> - - <br /> Disposal Field ('Specify Requirements)------ ----------- -- --- ::;--- _.--- - <br /> ------- <br /> ---------------- <br /> -------------- -- <br /> F ! ~ -- _----" -- --------------------------- --------- <br /> - -- -- -;- -- - ..-� __- ___ <br /> "--- ------ ----- ----------- ----_ 7L -rover. <br /> ----------------------- <br /> existing and rqu r addition o verse side <br /> (Draw i ed' i rj�re } <br /> I hereby certify that I have-prepared this application and rthat the work will be=done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of'the_San Joaquinkl.cical ealth District, Home owner or licensed agents <br /> signature certifi� the following: <br /> thi`ch <br /> �"I eerti thatin the performance of the work for this permit ist issued;El shall not employ any person in such manner as <br /> ` to become subject .to rk s Compensation laws of California.';f. .; <br /> t rO� <br /> Signed-- ' / ------- ---------e--_-,--- -- = Ow erg <br /> { ---------- ----------#._ ----- <br /> - Tithe_-f. = . <br /> # _ i <br /> I (1f other than owner) 1 ��F Y-w^�--- <br /> FOR DEPARTMENUSE-ONLY <br /> a tv ATE <br /> i APPLICATION ACCEPTED BY- _ = D <br /> i "^ <br /> -- - --- ver <br /> -- <br /> ' ' _ : --DATE ; I :;: <br /> -- <br /> D1V1510N OF LAND-NUMBER_ _ =__;--.�- .� ------------------------ <br /> ADDITIONAL COMMENTS------ - ----- ------------------------ --- -- ----- J <br /> ----- -- <br /> �} : <br /> _--------------------------------------------------- <br /> = =f�� �--.�------ <br /> r ----------=-- ----------------- <br /> -2 V <br /> = ---------------Date---- L1'- <br /> -------- -- <br /> i Final Inspection by: ----='---- -� - ----- -';,--- <br /> f, <br /> SAN JOAQUI LOCAL HEALTH bISTRICT f&s sl�! ,EV.7/76 3M <br /> EH 13 24 �.�®' <br />