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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. ..................... <br /> ------" (Complete in Triplicate) <br /> ._ .. .. . . <br /> _. .. m p Date Issued <br />_.................:------ <br /> This.Pern�li Ex iter ] Year From Date Issued <br /> rk herein <br /> Application is hereby made to the San Joaquin local Health District for a permit to construct and Install the wo <br /> I <br /> describedthis application is made in compliance with County Ordinance No. 549.ond existing Rules and Regulations: <br /> �� .... ,11 . ............... ........... <br /> CENSUS TRACT <br /> Boa ADORiss LOQ ION , .._ .._.......... 6 /,h�......... <br /> ............. c <br /> ,...... one <br /> Owner's Name -�0.�?...--•-- -----... .................... <br /> •--•-•--....., city .... .. . . ... , ............... .......... <br /> Address . . ...... ...., one <br /> --•- License . .... <br /> Contractor's Name�`��- ��- •�- <br /> ¢.. . . <br /> Installation will serve: Residence�artmen#Housed Commercial ❑[railer Court ] <br /> Motel E]other ................. <br /> Number of living units:_.......... Number of bedrooms _. ...._... <br /> Garbage Grinder .-.......... <br /> Lot Size :�7• .rSl ..................... <br /> _ <br /> .................I._.................Private [� <br /> Water Supply: Public System and name ---------------• •............. ..._...-........... <br /> Peat❑ Sandy loam ❑ Clay loam Q� <br /> Character of rail to a depth of 3 feet: Sand 1] Slit❑ Clay ❑ <br /> Hardpan ❑ Adobe [] Fill Material ............ If yes,type ............... ............ <br /> Plot Ian;" showing site a# Int; location of system inn relation to wells, Isuildings,,etc. must be placed on reverse side.) <br /> I P <br /> i NEW INSTALLATION: (No septic tank or seepage .pif,permitted if public sewer is available within 200 feet,) <br /> SEP-TIC-TANK I _......---•t---•.. ....................... T• ;.LIquld D <br /> ep <br /> th <br /> V ................... <br /> PACKAGETREATMENT.& I NoCompartments ......................... <br /> , oterial•-•-......:...--•..... <br /> Capacity .. TYPe ................ mMLine ..................... <br /> - Foundation"`.............. " Prop. <br /> Distance to nearest:-Well ......... • <br /> y <br /> .................. <br /> -No. of lines ...... Length of each line . -- <br /> - ... Total -Length <br /> LEACHING LINE Depth Filter Material .......................... <br /> .......-- <br /> 'D' Boz ............ Type Filter Materiai ....--••-....-•-•• . <br /> .,.� ,...�> <br /> ..... pro er tytine ....................... <br /> Diston(5'10 nearest; Well ....... ........ Foundation !� <br /> -" <br /> Di <br /> ----•....... ......... ok Fil <br /> led `Y-es ❑ No ❑ <br /> ameter Number <br /> SEEPAGE PIT Depth <br /> Water Tabls:Qe thV .........................Rock Size ....•• ...................... <br /> € Pro Line •---•• <br /> Distance to nearest. Well ................... <br /> _ ...._Foundation ._•_......_._...:..� p. --•--••--•-..... <br /> _REPAIR/ADDITION-(Prev:.Sanitation Permit# -•--------- --------- <br /> Septic Tank {Specify Requirements). - - --------••-• .. .................. <br /> Disposal Field. (Specify Requirements) --•--- -- / D .?, I . <br /> �� i ...... <br /> _ I <br /> ._... °:... - -------------=------•--.._-... .:-----... .............. <br /> -------------------------- -------•------- <br /> i <br /> (Draw existing and-required addition on reverse side) �`����yt��;�, <br /> I hereby certify that ! have prepared this application and that the work will be done in attordance:with San`=.lo 1 on- <br /> 'W-ii Or <br /> Ordinances, State Laws, and. Rules and Regulations of the San Joaquin LOCaI Health ©istritt. Ham• euln <br /> wnee ar licen- <br /> `sed'gents signature ceHifies the•Followirig: arson In such manner <br /> ( "I certify that in the performance of the work for which this permit is issued, 111sholl not-employ any p <br /> l as to become subject to Workman's Compensation laws of California." , . ✓ ';t `� . <br /> ----•---•----••-• --- Owner <br /> Signed k. ,r <br /> �orTf <br /> ...--- ...._ <br /> By -•-- •- - --------- • -................--•------------------------------------------• ---- Title <br /> (if other than owner) <br /> R DEPARTMENT USE ONLY <br /> . ...__._.. DATA l --•-- <br /> APPLICATION ACCEPTED BY _�.'_ --- - ---- ------•--------• DATE ... ...-- ... <br /> BLIlLDING Pi=R1NIT ISSUi=l3 �` .. <br /> -• -- <br /> ADDITIONAL COMMENTS ------------ • ................. <br /> -......_.--- ............... <br /> .. --------- <br /> .. ..-. <br /> i 3 <br /> } ----------------- ----------- ........... . ... '` .-- -------�--......._-.._...-Date ....- ---- • -- .. -. .._.._.. <br /> Final Inspection b <br /> y: .... _ -- ----------- ---- ....... . ,r ,F 8/7h 3M <br /> �' EH 13 24 1-68 Rev. 55M SAN JOAQUIN LOCAL HEALTH DISTRICT <br />