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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------- - ---------------------------IN-------- Permit No.. .. '' ��✓ � <br /> (Complete-in Triplicate) <br /> --------------------- --- -------------------- --------- <br /> Date Issued.,__ .477 <br /> 11 This <br /> = Year From Date-Issued <br /> Permit Expires I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to c'onstrtict,and instalfi,the work herein described. <br /> This application is made in compliance with County Ordinance'No. 549 and existing Rules and Regulations: <br /> ,( CENSUS .TRACT <br /> JOB ADDRESS/LOCATION.---I_ ...!'.._ .._;- /l� 2'? -.---- '-:--- Wit..-- - <br /> Owner's Name---------- e - ------------------ ------.-..:------------------------'------- ,- --------Phone--------------.- - -- --------------- <br /> --f 1 - - k-ti. r Cit = = Zip <br /> -------- <br /> Address...-- - -- I: --- -Lice ,. ... / <br /> Contractors Name--- _. G` nse #- OF/7/------Phone--�-�/__!�-��� . <br /> Installation will serve: Residence �: Apartment House❑ Commercial ❑ Trailer Court ❑ ' <br /> _ s <br /> c. . Motel F-1 Other----- ---------------------------------"- <br /> t <br /> Number of living.units:-- <br /> nits: - Y______Number of bedr ms,-_�_;---Garbage Grinder____.___-__Lot Size---_ �1-- - ----------- ------------- <br /> Water Supply:.Public System iand.name----- - '` '7--------------------------------- ------------------------------------.:----------------Private .❑ <br /> Character of soil to a dep�h of 3 feet: - Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam E] <br /> Har Apan E] Adobe❑ Fill Material.............If yes, type--------------•----------------- <br /> ]Plot plan, showing size of lot, location of`system'in-reiation-to wells-b'uildings-,;etc"must be placed on reverse side.] <br /> i -NEW INSTALLATION-" (No septic tank or seepage pit permitted if public sewer is'available within 200 feet,] <br /> '� i S <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ['] Size______ �( ______________________'Liquid Depth_._�4._. <br /> 1 <br /> ] . ---: YP of --Materi r. - Compartments Line- <br /> f A rapacity- �_ .Q T e �,- <br /> Distance to nearest. Well.....- &-------------------------Foundatioh t--_- �---- -_ -� o . <br /> t -. w ` P -- <br /> . 9 [ ] No. Lines--._. -.-- Length of each lin®.......... .. ...f._~.-..Total Length .._. <br /> . . = �. <br /> i <br /> 'D' Box ----Type Filter Material----_-` --Depth Filter Material...-�- ` -' ------------- .----:-----------. <br /> t •rest: Well-=--------------------------Foundation----- <br /> Property Line <br /> Pro e <br /> 46PAGVle [ ] Destth �'Wameter--------------- ----Number._---` ---------------------- p Rock Filled Yes No <br /> Water Table Depth <br /> Rock Size-- <br /> ----- <br /> E 14o, I. <br /> ------ dationDistance to nearest: Well FounProp. Line ----------- ---------- <br /> REPAIR/ADDITION <br /> .._._REPAIR/ADDITION (Prev. 'Sanitation Permit#.....:._ .................. --Date....:------------------ J I ------------- ' 7 <br /> - <br /> Septic Tank (Specify Requirements)--------- =----------------------- --------=-------------- `-------=-----`F <br /> - ' -'-- ------ -----------`-=-----=------- --------- <br /> Dist osal Field (Specify Re ulrements)_-____ � , <br /> --------------=------ ------------ --- -------- - ------------------------------------------------- -------------------------------- <br /> - -------- -- ---- - - ------ --------- <br /> a <br /> i € =------------------= --- ------------- ------ -------- ------------------ --- -- --- -- - ------------------------------ <br /> :? A <br /> (Draw existing and required add itianronreverse side)/ ift <br /> I 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 HebltW Dist[ict!Hon owner or licensed agents <br /> signature certifies the following: f _ <br /> "I certify that in the perforlm ance of'the work for which this permit,{is issued, I shall not employ any�persori in such manner as <br /> to become subject to Workman' s. Compensation: laws. of California." <br /> Signed------ -- -- ---= - -- ----- ---- --------•-------- --- - -------- <br /> BY -/Own <br /> er <br /> Title , <br /> t <br /> „ (If other than owner) i t, <br /> FOR.DEPARTMENT USEµO LY,7,i <br /> APPLICATION ACCEPTED BY ----------------------- t ` DATE. --y-7- ----- --------------------- <br /> DIVISION OF LAND NUMBER --------------------------------------- --- ------------- DATE ------ <br /> a <br /> ADDITIONAL COMMENT --- -- -------- - <br /> - -- --------- -------------------- <br /> ---------------- - --------------------- ------------------- ---------------- -- ----------------------------------------- -------------- o <br /> 0 1M - ------:---- /----------- --------------------------------------- ----------------------------L - ----------------------------------------- --- <br /> ----- ` <br /> Final Inspection b —� Rl - ---------------------------------x -=--_-----Date.------ <br /> P Y� - =-- �° <br /> - -- - ---- - ---- <br /> EH 13 24 �� AN-JOAQUIN LOCAL HEALTH DISTRICT ras slbn REV. ���6 3M <br />