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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 71ssued.3 <br /> FFICE US�Y&411 <br /> --------- - .p(Complete in Triplicate) [Date <br /> 7i_7n/ <br /> ---------------"---"------------------------------------- This Permit Expires ] Year From Date issued _ -/ 7� <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 /> JOB ADDRESS/LOCATION--- /5®e":_- ; �2n _ . : - •` ` 'y <br /> Owner's Name. ----------- <br /> - <br /> --- ------ - ---------CENSUS TRACT.---- ------ <br /> ----------------- <br /> Address-- - - ------------ ;_ ------- -- -- -- - -- ------------Phone-------------------------- ----------- <br /> -- <br /> ----- <br /> -....� - -.City -- -- - -- -- <br /> Contractor's Name : ems ..'...� Zip <br /> ' � 1 <br /> - � ------- ------ �---=License #_-.�-_�_.r,ZZ� Phone <br /> ' <br /> Installation wifl7serve: -„ ; ❑ _ Phone---------------------------------- <br /> EZ", <br /> ---------- - - -- - I <br /> P _ <br /> Residence � Apartment House Commercial ❑ iTrailer Court ❑ <br /> .. <br /> g Number..of bedro s_ O r-Garbage Grindar _, _-_, _Lot Size <br /> t dtel _ <br /> Water Supply: Pu I' <br /> 4 pp y: b is System r / <br /> K if l a - p <br /> ------- <br /> Number of liven units:____.___. <br /> Y and name <br /> Character of soil to a depth of 3 feet: ,. Sand ❑ :Silt Cla ❑ y �! Clay L Private <br /> y ❑ Peat Sand Loam y oam ❑ <br /> ri <br /> Hardpan ❑ Adobe.� -s Fil!Nlater'iaL_ "'�'""I{ -estype <br /> - '-----------------(Plot plan, showing size of lot, location of system insrelation to wells, ; 1 <br /> y buildings, etc. .must be placed on reverse side.) <br /> NEW INSTALLATION. (No septic flank -or seepage pit permitted if public sewer is available within 200 feet,} i <br /> PACKAGE TREATMENT [ ] : SEPTIC TANK � <br /> l Size ----- <br /> r -----------------------------Li 'd D h <br /> squi eat .. <br /> Capacity T <br /> - t <br /> YPe -- --:-: MatariaL:_"- _-- - No. Compartments-------------------- <br /> Distance <br /> to nearest:.Well '*, _ <br /> _ - <br /> LEACHING LINE' _ w ,. ,, wC n -- ----- {Pr p ----------- <br /> ------- j <br /> Foundatio •. ,_ o LineR <br /> i '1 . Na: of Lines-:.,, {w------Length of each line. `= = f. ::_dotal Length <br /> 'D' $ox__ __Type Filter�Material_:_ ." __ ------- r real <br /> Depth Filter Mate <br /> - - t •:- h. . - - i ------------'------------------------------- <br /> Distance <br /> -" - -" --- ---- -- - ------------- <br /> --------------------- <br /> ---- --- <br /> r - <br /> t to nearest: Well =------------- �undntian -- Properfiy Line_-_ <br /> Distdnce <br /> SEEPAGE PIT .....: - - <br /> p ----------Diameter - ----.Number-­ <br /> -----------------------------_� - R <br /> Water Table.Depth.__` ___ - <br /> Yes ❑ H <br /> Rock Filled Y s ❑ No <br /> ' __.RockSi" <br /> ze <br /> f <br /> - <br /> ; - ----------------------- <br /> Distance to nearest:We11 --------------------- 11 <br /> ------Foundation ---- .Prop. Line a <br /> REPAIR/ADDITION Prev. Sanlitation Permit#__ f------------------ --------Datd-----_----------------------------------------- <br /> Septic <br /> Tank Specify Requirements)__-._ ) <br /> ------ ------------ "= = •- - ._. <br /> Disp al Field (S(Specify Raquirementsl_---_".- -- _-- I - � .•_"` � ----------------- <br /> -------------- <br /> -- ------------------------------ <br /> - <br /> -------- -----. _. • <br /> P Y <br /> ,'`.z`� <br /> ------ ------ <br /> - ---- _. <br /> ---------------- - .------- <br /> ----- --{Draw existing and re uir-ed ---- <br /> -, ... . . . - �. - 9 --- q addition on r-- ----- ---�-----•- --=- --- -------- ------- --- ----- �------ ��--- <br /> everse side] ? <br /> I hereby certify that.1 have prepared this application and that the work will be done in accordance with <br /> Ordinances, State Laws, and Rules and Regulations of the, San Joaquin Local Health District. Home owner or licensed ens d agenaquin tS v <br /> signature certifies the following: <br /> "I eertify that in the performance of rhe work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workman's C6mpensaticm laws of California.". , 4 <br /> I <br /> Signed---------- <br /> ---------- <br /> I -- Dwner <br /> BY )}------ �( <br /> = .' <br /> ry y <br /> itle - --- --- <br /> '(If other than By- <br /> er) <br /> - <br /> k ... ___-____ <br /> own <br /> F DEPARTMENT USE-ONLY)"" <br /> APPLICATION ACCEPTED BY______-_'__ �_ <br /> - -------- -- <br /> ------ -------- <br /> .. ._. <br /> DIVISION OF LAND NUMBER------ DATE. -3 <br /> - ----------------------- <br /> ----- - ----------------------- - DATE <br /> ADDITIONAL CC}MMENTS------------ - -------------- ------ ............- <br /> - --- ---------- <br /> E =------- ---- ---- -------- <br /> - -----: - -- --------------- ------------------ <br /> 1 --- <br /> } _ -- --------------------- <br /> ---------------------------------------- ..., _ <br /> ---------------- <br />---------------------------------------- - -- ----------------------- - <br /> ----------------- --- <br /> - <br /> Final Inspection b ----------------------- _ - _ ____-_ _ _. <br /> Y" ------ _ _ + <br /> -----=-'--=-------Date- ) --- <br /> ---------------------- <br /> SAN ' .. <br /> EH 13 24 JOAQUIN LOCAL HEALTH DISTRICT F 5 21677 REV. 7/76 3M <br />