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FOR OFFICE USE.. FOR OFFICE USE APPLICATION FOR SANITATION P11ERMIT , <br /> ----------------------------------------------- --------- <br /> (Complete in Triplicate) Permit <br /> ------------------------------------ ------- ------ <br /> ........ -----------­---------- -------------- --------- This Permit Expires I Year From Date Issued Date lssued ---'_ �n_ <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 mi.ade in c��mpliance with County Ordinance No. 549 and existing Rules and.Regulations: <br /> JOB ADDRESS/LOCATION..-- ---•.-CENSE!: S TRACT.......... <br /> ------------------------------------- <br /> Owner's: Name------ 7�- <br /> 0. <br /> ------- ----------- -------- ------- ------------­-----­---- --------- one--------­---­------ -------- <br /> Address-- ------ <br /> ddress---------- <br /> - ------------------ ----------------------I------ ----- -- ---- ---------- ---zip.......­­---------------- <br /> I ,- - 11 .-, -..�; 6. <br /> .... --------- <br /> Contractor's�Name- h zo-,Vz3c?-�!!�U <br /> Re, ------------ 1icense # ­­­­------------ P one- <br /> lns�allation Will;swX'e sidencq Apartment House El Co a 0 Trailer- Court 0 <br /> Motel E] Other-....------------------­.............. ------ <br /> r Or T, <br /> Number of living uniis-­--. Lber of bedrooms....3--Garbage Grinder............Aot Iiz­ Or -- -------- <br /> ' 8 <br /> Waper,Siipply. Public,system and n6me--..... -- ------------------------- -I........ ---------- ----------------------------------- --------------------­ Private <br /> Character of soil:to.a'deoi <br /> ,pth 3`fa ti �e't: Sand ❑ Silt(3 Clay E] Peat 0 Sandy Loom [3 <br /> Clay Loom E]l <br /> Hard an'E] Adobe:[] Fill Material._ ----� -.-.Ifygs, type--..--------- - - <br /> ------------ ...... <br /> {Plot plan, showing size of lot, lotatioh of syste'm in relation to wells, buildings,etc. must be placed on reverse side.) <br /> NEW INSTALLATIOM.- (No i6ptic tank or seepage pit permitted if public sewer is available within.2004eetJ <br /> PACKAGE TREATMENT] �EPTIC TANK �ize.------------ ....... -----------------Liquid Depth.'-------------------- <br /> Cap at-ity------- --- ------Type-------------- Material-------•-------------- ....No. Compartments----------i------------------ <br /> DistdU -it: Weil________-------­------- ---­--------------Foundation----------- - ------ Line-.:----------------- <br /> nce\,to nearest: <br /> LEACHING LINE No.'of Lines— ------- --------------Length of each lins,­.­.'.�--- ------- Total ........................ <br /> D' <br /> Box--._--_--.__Ty Filter Material—--- -- -----------Depth Filter Material..----. .- ------- .......... .......... .................... <br /> es <br /> P <br /> .Diameter------- <br /> ... ... .........Len-g, <br /> h <br /> Filter Material— <br /> o ........ <br /> Di tdnci5 to nearest- - -----­--- ------Foundation----------------------------Property Line---- ------- ---------------- <br /> I a t r------------ <br /> --------- <br /> SEEPAGE PIT Depth---- --- ...... ....... . iumber--------- Rock Filled Yes ❑ No <br /> -- ------------ ------------------------ <br /> p . ... <br /> Table'Depth.................. -------------­Rock Size.------------------------------- ............... <br /> Wate" <br /> --------------- <br /> Distance to nearest- Well------ <br /> ----------- -- --------------------Foundation—....... ----- --------.Prop. Line.... ------------- --------- <br /> REPAIR/ADDITICIN 10rev. Soni ation Permit#------------- ---------------Date---------------------------------------------- <br /> Septi c'Ta n k (Sp'cify Requireml nts). <br /> --------------------------------- ------------- --------- - ---- -------- <br /> Disposal (Specify <br /> Field Requirements ------ -- <br /> - ------ --- -------------------­.......1�1------------------6........... <br /> , <br /> ----------------1-------- J ------ <br /> ----- ------------- ...... ------------------------------------------------------------------------- --------­­-------------------------------------- .............. <br /> - <br /> ----------------­ <br /> -------------- -------------I---- -------------- ----------------'-------------r--------------------------------- --------------------------------•-------------------------- ­------------ <br /> (Draw existing and required*aadifion on reverse side) - <br /> I hereby certify that,I havepp, <br /> prepared this application and that the work will be done in accordance with 10n Joaquin County <br /> Ordinances! State Laws, and Rules and Regulations of the Son.-Joaquin Local Health' District' Home owner or licensed agents <br /> siglature certifies the following. <br /> "I ortify that in' the perform'uncefof the work for which this permit is issued, I shall not employ any person ln' such,manner as <br /> or <br /> to become 'Subject to W. kman's Compensation- 71—aw-s of Califdriiitcl <br /> Sig ed--- -------------! . .......I <br /> ----.-.-------- ------- -----------=-------- •------ ----------Owner <br /> By--------- ---------------- ----------------- .......Title --- ------------------------------------------------- -------------------- <br /> ------------------- ---------- ------ <br /> 4 jt <br /> 11f otAer than owner) <br /> FOR'DEPARTME14T USt ONLY . . . . . . . . . <br /> ----- ...... <br /> APPLICATION ACCEPTED BY-4 ------ TE <br /> DA <br /> ----------------------------- --------- --- ------ ----- - <br /> DIVISION Of LAND NUMBER.t------- ......... <br /> --------------- --- --- ------ ----------- -------DATE----------.-----.---_-- ------- <br /> ADD ITIONAL.'COMMENTS- ------------------------------------­-------- : .- <br /> ---------------------------------------------------------------------------------- ..................... <br /> 4 <br /> -------- --------------------------- .............. ------ -----------I------------------- <br /> ------------------ -------------------------------------------------------------- ------------- .......... <br /> ----------- .................................................. <br /> -------------- - ----- -------- ------------ ----------------------- ....... ............. <br /> 4- <br /> ----------------7- : --4-- -­............ ------------------ -------- - --------------------- <br /> -------------- --- - ----------- -- --- ------------ -------- ------- <br /> . .4i - <br /> Final Inso6ction by-------------- -0 <br /> --- . --- ----------------- --------------------------------- -- -------------Date-.­ -1'-.77------ T- <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />