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r \~� <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------- ----------- (Complete in Triplicate) <br /> Permit <br /> -- - <br /> No. <br /> ---------------- ------------------------ ------------- w Date Issued._r� . J7 <br /> _----_-___._- ".............. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San JoaquinNLocal�Health*District_for,a permit to constru'c`t and install-,the work herein described. <br /> This application is made in compliance with County Ordinance No:549`arid exisi�ing Rules and'Regulations: p w <br /> ' b. ( ------ ---- ------ ---- - t-- - TRA ------- ------ <br /> JOB ADDRESS/LOCATION__ ,. __._/-�____. .._ CENSUS CT.- .; <br /> - - ---- --- hone--------------- -------- <br /> Owner s Name fes¢ -------------- ------ ---- ------ _. _ .. <br /> Address------ -;G yi'tJ - = - ---:-----. <br /> City ZIP <br /> 's Name_-.-_ - ----------------------- <br /> ContractorL se <br /> Installation will.serve: Residence11: Apartment House.❑ Commercial ❑ ;Trailer Court, ❑ <br /> ffti� �°�*M•otel-E­Other---- - ...........----------------- <br /> .Size--. <br /> ------ W <br /> Number of living units---_---- Number.of.bedrooms Garbage.Gnndar._ Lot, - <br /> Water Supply: Public System_ and name- ` ' -- -___ ------ . ----------- e <br /> r: <br /> Character of soil to d depth of 3 feet: Sand ❑ Silt ❑ wClay 0 Peat-0. Sandy Loam ❑ Clay Loam + <br /> I Hardpan n ' Adobe❑ Fill Material-. __If ye type----- --- r <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings etc must be platted on reverse side.) v i <br /> I within 200 feet <br /> NEW INSTALLATION: [No septic tank of seepage pit "permitted if public sewer is availab a .,1 s <br /> ti _ Size..__ '� �. - Liquid Depth ; ' <br /> PACKAGE TREATMENT ['] SEPTIC TANK[ ] "" -=--- --- <br /> Ca acit f d ;� e:= = Material= '-•_' No, Compartments.-- -9-- <br /> P Y = <br /> . TYP, j <br /> -"` -- �� <br /> Distance to,,nearest:gWelL -' ib2---------•------- - -.__Foundation --0-----:r--- --_=,Prop. Line----- ------------------ <br /> - , --_ .:::[ f each.lirie ' Total Length..: --- --Qb- :' -� <br /> NG LINE: [']rNo es.`_�_ Length_o QQ-..=__- --,:. <br /> LEACHING `D Box.-..-- -----Type Filter Material-------------- Depth Filter Material---`_-----_.------_-.---------" - ------ ,-------- +� <br /> t <br /> I _ ... ;... s .�. t• '[ # [' Distance to..neare.,st: Well--- <br /> el!_,_... .;i! _. --` _ Eoundation__.._,__.; _.P.r�o p <br /> rty Line---- ------ -- ------------- <br /> PIT Depth -__ -.-Diameter.-_ --- Number-------------------------------- RockFilled Yes❑ NoSEEPAGE <br /> ' U <br /> Water Table De`th ._----- ,--- .. <br /> � t p. ~� ------------=-- Rock Size:- ------------ --------------------- - . -- - <br /> E Distance to"nearest:Well:.. - ' .. .' R' - <br /> --..Foundation - Prop, Line. . <br /> Prev. Sanitation!Permit#--`------------ -- --------i_-----� Date:__:__-_-_: `- -------------- <br /> REPAIR/ADDITION � � <br /> r--- <br /> -; .__ ... ---------------- ---- -- <br />- Septic Tank (Specify Requirements)-_____ -- ---:--�---=---------------------------=-=�- --------------- -------_-- -- --------------------------- ------------------ <br /> Field [Spec(fy Requirements) ---------'----- ------------- --- -`------=----------------- ----- ----------------------------------------:� t <br /> - ------ --- <br /> - ' <br /> [ ------- -------- --- -------------_----- r- -- - --------------------------'.----------------------------------------------- -------------------- <br /> e- <br /> ----------------------- -------------------:------------ <br /> (Draw existing -and required addition on reverse side) i t Y <br /> I hereby certify tha I have prepared this'application and that the,.work will be done in accordance with -San Joaquin Court <br /> Ordinances, State Laws, and Rules and Regulations of:the Sari Joaquin Local Health District, Home owner or licensed agent <br /> r signature certifies the following: w <br /> t <br /> "I cerci that in the performance of the work for which this permit is issued, '1 shall not employ any;`person in such manner as ' <br /> to become subject to Workman's,Compensation, laws of.California.':.- . - <br /> ----- -- <br /> [ <br /> ' <br /> i< <br /> OVnerSigned - --- -- Title - t_BY-i----- --- --. Yjlfother'than'ow DEPARTMENT'USE ONL --•- <br /> g . <br /> APPLICATION ACCEPTED B ---- . .-. _ DATE.-.-',- <br /> -------------- <br /> - ( = <br /> DATE �;". ' <br /> DIVISION OF LAND NUMB --- ----------------=----------------------------------------- DATE f <br /> ADDITIONAL COMMENT - --------------------'---. -------- - ---------=---------- <br /> f <br /> Y --------"----------------- --- ------- <br /> I -- ------------ <br /> ------ ----- . ----..---- - --- -- ----- ------ ----- ---=. ----- <br /> : /" <br /> Final Inspection kb - -- - ---Date.- - ! <br /> EH 13 24 S,o,P4 JOAQUIN LOCAL HEALTH DISTRICT &s Z'6� ,v. 7 76 3M ,i <br />