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FOR OFFICE USE: <br /> vii% FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- Permit <br /> (Comple� in Triplicate) <br /> --------------------------------------------- - Date Issued._ <br /> :"--------------------- This Permit Expires 1 Year'From Date Issued <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/LOC N._._.r1.�'Q --."- - . CENSUS TRACT' <br /> G . <br /> Name _ ------ ---- -------------- <br /> Owner'sone <br /> ct./ _.. -Ph <br /> Address ------- ------------ <br /> City ------------ - -------------- <br /> .. -- <br /> P <br /> �- <br /> ----------------License #.----3c� 7 / Phone_. :- fes <br /> Contractor's Name_`--[..�---------------------,���--- � - -- . <br /> Installation will serve: Residence Q Apartment House Commer Jal E] Trailer Court ❑ <br /> Motel ❑ Other__ -�_ ;. . ..,: <br /> ' ' <br /> nits: // ____.Nurriber of be <br /> Garbage Gr.inder__s--___=_.Lot Size-__._ �_ ------------=------------ - <br /> Number ofIiving•u, -_1- -- <br /> y � ystem and name------------------ ` - Loam -------Private <br /> Water Supply: Pub it 5 _ <br /> - ------- -- ----- <br /> t .. l <br /> Character of soil to'a depth of 3 feet: ' Sand ❑ Silt❑ Clays❑ Pea ❑Sandy:' '❑ =CIpY Loam [ _ <br /> Hardpan E]:'"-AdalSe ❑ FilrMaterial- > �if yes,y.type_ ' <br /> - <br /> (Plot plan., showing size of fot3lo a ion of system in relation to-well s,'buildings, etc.`must be placed on reverse side.) <br /> NEW INSTALLATION: (No seplkc-fank-or seepage pit permitfie-cif public sewer is available Within 200 feet,) r r t L.1J <br /> PACKAGE TREATMENT [ ] * SEPTIC TANK i Siz ._!-_�___ __.______✓_L l-� Liquid Depth -- --- <br /> PACKAGE <br /> acct �'� T a-• - Material___ <br /> h3 ' ` ------ ` Compartments_ '� <br /> / ,cJ N o <br /> F p.. Y--�� YP F <br /> Distance to nearest Welles--'.-© ------,} .- ----Foundation--- _---- -,- Prop. Line__-=------------------ <br /> �c '. <br /> LEACHING LINE [';]' No. of Lines-_ ___ Length of each fine tQ :- Total .Length.___.__ .,_,.---_-__ <br /> t <br /> D' Box _Type F Iter Material" !l - yDepth Filter Material------4?._�.;_ .___.. <br /> ry� -� N—? _ Propert Line -------- ------ - <br /> Distances to nearest: Well._�-!-___ _,__Foundation__ -_.__;_ y --- <br /> r <br /> �`� ''^ RockFilled 'Yes o <br /> SEEPAGE PIT [s-}� Depth_ _. _ _.Diameter.•__ .�_- Number__ : _ ___ Roc <br /> per- -----� =------------'---- .Rock'Size-------------------------- ---------------- <br /> Water Table:Depth_.�___!-._"- <br /> \J i s on"- � � <br /> Distanceao nearest: Well _ -----------------. -------------Foundations :_.Pr'-op. Line---------------_-------- <br /> REPAIR/ADDITION (Prev.'Sanitation Permit#--------- --------_----_ <br /> °� '-------__.Date = --�--- . ---- 1 <br /> Septic Tank.(Specify Requirements)--=---------:--=---- i.--_ - ---------- ------ ------------ <br /> ------------------------------------------- <br /> Di <br /> ------- <br /> Disposal Field (Specify Requirements)--------------- ------ ----------------------- ---- ----------------------------------------------- <br /> ------------ <br /> -- =------=-----iti-------`A~----------- _ y _ <br /> ------ --- -------- - ---- ------------- - - --- ------------------ <br /> ------------- <br /> -- ------ <br /> ( I ' - ------- --- <br /> -------------------------------- <br /> =------------=----------------------------------=---------------------------------- ----------------------------------- <br /> -- --�- ---------_ ----- <br /> -- -- - - r ,�_;; <br /> � � (Draw existing-and required'ad dition=on reverse side) <br /> hereby certify that I 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 /> signature certifies the following: ; k -- <br /> "I certify that in the pei`formance`of:the work for which'-this permit is issued, I shall noC employ any person in such_manne as <br />+ to become subi to Wor an's Compensation.„.laws,of California.". <br /> t Signed-= _ -------I - ---- - ------- - .- <br /> Owner <br /> Byl -- e L f <br /> ------------ <br /> Title <br /> Of other'than owner) <br /> . 'FOR DEPARTMENT USE ONLY' <br /> _.. a .DATE.. - i <br /> _ - - - --- <br /> - <br /> APPLICATION ACCEPTE D"•BY_ _'� " <br /> DIVISION OF LAND NUMBER.` ----------------= - :: -.---------------- -.-_-DA ----- <br /> TE -- <br /> 9 ADDITIONAL COMMENTS------ -------- - --------:------- --------------------- ----------�------------------- <br /> = ---------------------------------- ---------'----=-----=-- -------- " <br /> -------------------------------- ----------------------- ------ <br /> - F <br /> - 4 <br /> _ _ _ ------ <br /> __________________________________________________ __ ________________ ____________ <br /> • _____________ _______�..ry.__l __.______--___ <br /> ..____..__ _ ._ _ 1 _____________________ _ _ _ - __ -__ _.______.-___ <br /> . -- Dat--------------------- -- - ----------- <br /> at------------------------ -- -- -------- <br /> r- - Final s inspection•by:. - - `T _ <br /> EH 13 44 SAN JOrUINF&S 21577 REV.7176 3M <br /> LOCAL HEALTH DISTRICT <br />