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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT I° <br /> --------------------- --------- ---------------------- _ ! <br /> (Complete in Triplicate) Permit No.-� = <br /> -- - - ------------ --------- l <br /> -------------------------------------------- -------- This Permit Expires 1 Year From Date Issued Date Issued-e=/—,2e <br /> Application is hereby made to the San Joaquin Local Health District for a permit.to construct and install thework herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ! <br /> m -........ _.�,...... <. . ,/� 11"' t -CENSUS <br /> JOB ADDRESS/LOCATIO -.._..--�oI .'_-" tee _ ' <br /> [ - y - TRA - <br /> Owner's Name ---- --- --- -- ' ' _ Phone <br /> r ---- - <br /> • T <br /> ..�✓< ------------- - City P <br /> - - <br /> Contractor's Nanie:-'------ ------`-- ------ -�G-- _.. -------------°---------------------License #--------- ---------------Phone-I----------- s <br /> Installation will serve: Residence Apartment House.❑ Com mercidl ❑ Trailer Court ❑ <br /> y _ .r:- ; : Y.Motel ❑ <br /> Other-------------------------------- ------------ <br /> Number of living units:__ :------Number bf bedrooms-_- -_--Garbage Grinder-- ,----- Lot.Size -_- ------- ----------------- - --- -- <br /> s. <br /> Water SuPPIY PublicS stem and-name--- ------ - <br /> / f ---- -- ,Y= - Private E]Character <br /> of soil•to a depth of 3 feet; i Sand ❑ --Silt❑---Clay E]—Peat ❑ --Sandy Loam - •Clay Loam ❑ r- = .4 <br /> Hardpari ❑ Adobe.❑ Filf Materia.l__.______.._I€yes, type:----_ - <br /> ..r-.� <br /> (Plot plan, showing size of lot, location of system in relation to.wells, buildings, etc.must be placed on reverse side.) ) <br /> NEW INSTALLATION: '(N0-$1`s e"o-ti ctank or seepage pit permitted if-public seer is available within 8200 feet &r <br /> Zi <br /> PACKAGE TREATMENT / <br /> 'Liquid Depth----'--.: -- _ _'_ <br /> [ ] 5EPT1C TANK Size-----=---- ----- <br /> Capacity.a d7- . YP ®F ,fes _ j ,Z 4 <br /> ✓' No. Compartments <br /> ------------ <br /> t. Distance-.to nearest: Well e = - - ---ataria Foundation___-_........... ....... ..Prop. .Line-'- -------------- <br /> LEACHING <br /> LEACHING LINE s 'No_.-,,of Lin.es---------� Length of.eaclinep----. �-.--.---�-----------_Total/`Len:' <br /> �e <br /> n(_ft <br /> h _vf�---------'----------- <br /> _ <br /> g <br /> ---Type Filter Material,- -.-__--_ ------------------------------- <br /> D' box--:- � G - -Deth FilterMateigl- ---- <br /> � :. <br /> :Distance,to nearest: Well.'3 ._.-_Faunddtio.- b ,'_--: __Property Line----- � <br /> 17 <br /> .. .< ..,_.M .. .. .. ... . .... �.�... <br /> SEEPAGE PIT [ ] Depth __-.- . Diameter --- --------------Number __----- -_ _ --------------- Rock Filled Yes E] No'❑ <br /> Water Table Depth---------- -- -----------Rock Size------------- ' <br /> � ------------------- <br /> ( Distance,to nedrest:Well--;-------------- <br /> - ---- -----'FoundationProp'"Line------------------------� <br /> ------ - �-------------------- <br /> REPAIR/ADDITION (Prey:Sanitation-Permit#-------------------------------------------------------Date-------- ------- ----------_-_____----__._._ _) <br /> SepticTank (Specify Requirements)--- ------•--------- ------------------ ------------------------------------------------ ----------=------ --------------------------------------- ---------- <br /> Disposal Field(Specify Requirements)-------=--------------- ------ -------------------------------------- ;---------------------------------=-----:---------------------------- <br /> ------------=-------------------- --- ----------------------------------------------- ------------------------------------------------------------------- <br /> -------------------------------- <br /> f <br /> ------------------------------------- --- ------------------ <br /> ----------- -- ---------- <br /> -- ---- -------------------------------- -------------- <br /> - -=--------------------------------------- <br /> 1 (D'r`aw existing and required addition on reverse side[ <br /> I hereby certify that I have prepared this application and that the work will-be done in accordance with Son Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: - ti <br /> "I certify that t 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 Work an' Compensation laws of California." <br /> SignediYlr Owner <br /> ------------ <br /> BYi-------------------------------- ------------------- .-------Title--- -------------- - ---------- _ � r , 1 <br /> - - <br /> (If o#her than,owrie') . . ,. ° <br /> FOR,DEPARTMENT USE ONLY r v " <br /> APPLICATION ACCEPTED BY-. _ - <br /> ` - ------ ---- ------DATE.----- [7 <br /> DIVISION OF LAND NUMBER.----- --------------------------------DATE <br /> ------- <br /> .. <br /> i y"Y`ADDITIONAL COMMENTS--------------------- - ed le,-H- -- --- <br /> = ---- <br /> -------------------- ------I----- <br /> =/ -- Date -- <br /> - Ir <br /> �! SAN JOAQUIN LOCAL HEALTH DISTRICT r r3s 21677 Rev. 7i76 3n <br />