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-_jOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION,FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> --------------------------------------------------------- <br /> Date Issued._7777--Z7 <br /> ------------------- ----------- ----------------- . This-Permit.Expires 3-Year.From Date..Issued.. <br /> —f—W 1-i—11 k) :�jt <br /> Application is hereby made to the San Joaqui'n,Lo-cal 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/LOCATI( 'ZIP. <br /> Z7 <br /> -------—------- --------- --------- ---------------------CENSUS TRACT----------- <br /> Owner's -----f �aA I------------------- -------- ------------ --- ---- -0— 40 <br /> .......IT— -Phone-Za <br /> Address----- --- ------------- <br /> ---- ----- -city. Zip--------- -------------------- <br /> ----------- ----I---- <br /> "PAL 's <br /> Contractor's Name-" <br /> ----------- -License -- ---- -----4C3---Phone--- d?Phone... <br /> Installation will serve; Re'sijenc; Us—e <br /> Hon—G—mmercial"Ej 'Trailer Court F1 <br /> Motel ❑ Otl�er--- <br /> --- ---------- ---------- <br /> Nulmber of living.units:-- <br /> ----m-Number.bf.bbdroom.%_,-3____G6rbage.Grindef------..----Lot SizL.=..,e0 _,_' d <br /> W6ter Supply,..Public System an,I name---- --------- ----- <br /> ....... :-------- ------------------Private El <br /> C aracter of soil to __1 , "Silt El Clay ❑ Peat E] Sandy Loam ay Loprn El <br /> Character a depth of 3 feet- Sqnd <br /> -Hardpcin.- ff Aid'65e-ff Fill Material_- type_ ----------------- 4 <br /> (Plot plan, showing size of Idt, location 2fy0erri in relation to welis,�buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION [N6`;s'eP­tic- 'tank"6r'seeipage' pit permitted gLja�blit sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Siz--e-7-7-1: 17"!7--7------------------------------ <br /> -----Liquid Depth.:_-.-_ <br /> Compartments------:-------------- <br /> Cop6cltv-------- -:,T-Y pe-------------- - ..Mater4di------ ---- <br /> --------- <br /> ------------ <br /> Distd'nce to.nearc!st: Well........ ---- ----- -----------Foundation-1----- ------------Prop. -Line---- ------------ <br /> -- --------------- <br /> Ly <br /> N&of Lines-L-_-�--------- _.L�en4th—of-e-och in'e__ tol Length.'- --------------- ------------------ <br /> LEACHING LINE: <br /> 'DI Box - ._._.=._ <br /> Type Filter Material______' --------------Depth Filter.Mat&ial--------- <br /> -- - <br /> r --- <br /> -------- <br /> --- <br /> -----------------__.Foundation___._--- <br /> Dista' n&eto nearest: Well----- ---------Property Line. ------------ <br /> --------- --------- <br /> SEEPAGE PIT Depfh <br /> -- ------- ----diameter.------ ------ Number--- ------ -------------- ------ Rock Filled Yes E] No. <br /> El <br /> Water Table Deth.__' ------------- -----�___Rock 'Size <br /> --- --- ------ ------ --------- <br /> D <br /> istance.to near'est: Well - ---- ------------- -- rop."Line--------------- <br /> - --------------- --------- <br /> I P ---- --- ------ <br /> P # <br /> REPAIR/ADDITION (Prev. Sanitation e I -------- ------ <br /> _ Date= ------------ - ----------- ------------ <br /> • L CV�, <br /> Septic Tank (Specify RecIbirements)---- pi---------------- 1�4� : <br /> --------------- - ----- --------------------------------------------------------- -------------------- <br /> Disposal Field (Specify RequirerK�i-ffs-) .... --- -- ---- -- ------- --- ----- <br /> =------------Y n ...!4---�r----------- -- --- - ---A <br /> - - ----- ------------------I---------------------------------- -------- <br /> ---------------------- <br /> -- <br /> ----------------------- -------- <br /> (Draw existing addit' n'on reverse verse side) <br /> I hereby certify that.1 have prepared this,applicaflon--and= hat-.the,;work-will-be-dono -o'ccardance-with-San,Joaquin -Co I ty <br /> -iin un <br /> Ordinances, State Laws, and Rules and Rebulciiioni of`the Sarin t" - <br /> Joaquin Lo,�CIA�Ilth-Diiffri��Home owner or licensed agents <br /> signature cirtifies the following: rZ14 <br /> "I certify th'at in the rforrhanc of'the work for jwhic?h'ith1s'pe'rm' it-is issued, I shall not employ any-person in such ma:nner as <br /> c <br /> to become U olenscition SL 0 alifornia." <br /> Signed_ c <br /> ------ ---- --------- ----4&wfw <br /> ----------------- ------------ ----- <br /> By---------- ----- ------------------ ------ ------- <br /> -------- ------ <br /> (If other th'an,own'ei) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ----- --------------- ---------------------------------------------DATE <br /> DIVISION Or LAND NUMBER.--------------------------------- �:----------------------- ------------------------------------------- -- DATE..---.---- <br /> ADDITIONALCOMMENTS--------- - ---------------------------------- -------------------------------------- ----------------------------------- <br /> --------------------------------- <br /> -------------------------------- ---------------------- -------------------------------------- --I----------------------------------------------------------- --------------:-------- <br /> ---------------------------------I------------------------- ------------ -------------------------------------------------------:--------------------------------------- -------------------------- ------------ ------ <br /> ------------------------------------------ -------- ------------------- -------------------------------- ----------------------------------------- <br /> ------------------7--------------------- --------------- <br /> Fin6ldris"pection by: _-7 <br /> - —---------------------------- <br /> Date----- - <br /> ----------- <br /> ---------------------------- - ----:----------- <br /> EH 13 24 <br /> SAN JOA UIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />