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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR;SANITATION PERMIT q q <br /> ------------------------- --- - -- ---- l' Permit No.-"7l <br /> (Complete in Triplicate) <br /> -------------------------------------- -.--- ------- --- <br /> Date Issued__/_-_f-7Y <br /> ------------I-------_---------------I--------------------- This Permit Expires/,l Year From Date Issued <br /> if-I <br /> Applicdtion 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 Cou OrdinancefNo. 549 and existing Rules and Regulations: <br /> : - - '--..CENSUS .TRACT- "-------------------------' <br /> JOS ADDRESS/LOCATI N.. _ �---- '"""- .- . <br /> - <br /> Owner'� Name.--- -- - - - - - -- -=----- - - -- - -- - -----------------.------------------ - -- -------------- ---------- <br /> - - - -- -- ---- Phone_ _ <br /> Addres city <br /> Z ' <br /> -- --C i� <br /> qq rxw <br /> tontrmfor's <br /> l � aense # ------------------ ----=- Phone ne ---------------- - <br /> Ins#allation'will <br /> serve: Mi Residence Apartment House �] - Commercial ❑ Trailer Court ❑ , <br /> .._._ Motel ❑ . .Other--------=------- - ------m=------------- <br /> r <br /> Numbe; of living units:__ .__/___.__Number of b rooms :___Garbage Grinder.._:_.______Lofi Size__-.- _ -.�1 __._ .__ - _ { <br /> ! ,— a ° <br /> Water SupplyPublic System und_name --- - - ---:-------------- --------------•-_------------- - � Private ❑ <br /> Character of soil to a depth of 3 feet; = Sand Silt❑ Clay ❑; Peat❑ Sandy Loam 0 Clay Loam 2.1 <br /> _ E1_.._-. _ ! <br /> " Wdrdprn ❑ A o e , Fill Materia[----- ...If yes, type-------------------------------- r <br /> i buildings, etc..must be placed on reverse side.) <br /> [Plo'�plan, -showing-'size of lot, location of�ystem in relation to�wells, <br /> NEW INSTALLATION: �r{Nol'septic tank,or seepage pit permitted if p+�blic seweri's available within 200 feet,) "1 <br /> �� l _ <br /> i L - 4 <br /> PACKAGE TRE`AT01, <br /> MENI-_[ '] SEPTIC;TANK' '' Size _. - _ ;' Liquid Depth <br /> ` Capacit i: type- v .. aterial_. " 'No. Com art isg <br /> .Distance to_,near.-est:_WeII. .( -_ -_._Foundation \``-----------------Prop. Line_.------------------------- <br /> T <br /> __S_ _.__. <br /> LEACHING INE No. `of,Lines-___ .':____._ _ Length o .each li£te.__. .__- Tota[�Length °_1 ..---------- <br /> Lt I <br /> •` <br /> tw { <br /> I]' Box _Type Filter Material_ De th Filter Material_._. - _�� - t - ---- <br /> s �_ Yp . M. f r bine_.1S___ I <br /> . , p Y ---------- <br /> Distance to nearest: Well_; aundation_. --- -._..Pra e t L. __:__.._�_ _ _ <br /> SEEPAGE PIT ' Depth ZS'__€_�Diamet&_:_+ F.�� Numbe _ __ ; Rock Med Yes j'' 'Non ; <br /> .....J f. Rock Size - - � i <br /> Water Table Depth.- � ---- 7; -.:----- ---- --{-•- - . . --�------ r� R -- - <br /> x ] <br /> r <br /> r1, E_ .. }- <br /> Distance to.,neare'st:Well ,�z:_�J --.Foundation Sly :_._.__.__."_.Prop. dine.____._ ' <br /> REPAIR/-ADDITION {Prey:Sarfitation Permit#____ . prare::___ti L`r.-4 FD�ate-.------ ---: ------1 <br /> . -. --------- --f-""- <br /> Septic Tank {Specify Requirements)---- ---------------- - === : ----------- ----- ----- <br /> Dis os o! Field (Specify RL -----=--- ---- ---------------------------------` i -------------------------------------------------------------- # <br /> [ t} + _ - ------------------------------------- -1--------- <br /> ------------ <br /> ------------------Y-- - r , ., <br /> --------------------------- <br /> --------------------- <br /> (Draw existing and required�addition.on reverse sWde}�; j <br /> I Leby certify that'l 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. Home owner or licensed agents <br /> signatui a certifies the following: <br /> f <br /> "I#certify that in the performance of the work for which this permit is issued, I shall not employ any person in such Manner as „ <br /> E to lbecdme .subject to Workman's Compensation .laws of California.". C•1A.Rci1ti:-E'S SL'°'i. ,x c,"V;rP SERVICE � <br /> F <br /> -- <br /> S � ----------------------------------- <br /> e _Owner Cid <br /> f <br /> E -----..Title ------- ---' =-'-- ` - <br /> BY --I - ------ <br /> f t - [If other than ovfsner) <br /> a 'FOR`DEPARTMENT USE ONLY: <br /> APPLICATION ACCEPTED-BY---------------__ I <br /> ---- - ---- ------ - ---Q-�_------- - -------------=----DATE 4-__/_ ._l4 _..Z.T-- ---- ---.. <br /> DIVISION OF LAND NUMBER. = --------------.:--.:------ -DATE.: ' <br /> ADDITIONALCOMMENTS------- ---- k------------------------------------­ ------------ ----------- -•--------------------------- ----------- ------------------------ <br /> t ______________________________________________________________.______._.______._---_-_,-`-_-______________.__.._-_--------------_._____.'_____..______.____-_, _.._._.__.____..__.....___._.__._____._______ <br /> I <br /> - <br /> -----" <br /> _ <br /> -_ <br /> Final Inspection-b = -=- - --- --- ---a----------" Date f � �1� <br /> EH 13 24 ' SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br /> 5 <br />