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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE. <br /> (Complete in Triplicate) Permit No.--7-2-5'33 <br /> �I <br /> `' r Date Issued.-G.'.--y------ <br /> ----- ;f---- -- This Permit Expires 1 Year Irront,Date Issued <br /> Application is hereby made top the San Joaquin Local Health District for a permotto construct and install <br /> This application is made in compliance with County Ordinance No.549 a d existing`Rules and Regulat ons: work herein described. <br /> i <br /> JOB ADDRESS/LOCATIO a t <br /> - <br /> ' <br /> CEN TRAOwner's Name <br /> CT--- <br /> --- <br /> -- --- --- <br /> Address- -------- - -- ------ -----Phone_ <br /> e <br /> n - <br /> ' Ci� ----------- <br /> ----- - ..,:.,. ------ --- -- -- ---- - ---zip - �2Q� <br /> Contractor's Name.�t(J ---- ; <br /> .. <br /> Installation will serve: <br /> License <br />' Residence { <br /> �Apartment,House.❑ Commercial ❑ Trailer Court ❑ <br /> r... ; Motel"r tOthe�'_,_ - - i <br /> � ` . r r <br /> Number of living units:................Number-of bedrooms= _-- .Gacba e Ander___- _Lot.Size-__ <br /> `; l <br /> : �'`�$ g I <br /> Water Supply: Public System dnd name ' I ------ -- .--- . <br /> 9l: _ = <br /> Character of soil to a depth of 3 feet: • Sand Silt Cla, ' -------------------------- riv t <br /> ` . � , - -- - --- -- --- -------- --Private <br /> a �l <br /> t �p �1,�`;�,` ❑ 0 Peat❑ Sandy Loam ❑ Clay Loam <br /> t Hardpan ❑ Adobe.❑ FIJI Mate aC.` _--__If es y i <br /> Y type--- --------- ------ --- <br /> m8t plan, showing size of Jot,!location of system in relti,o to'wells, buildings, etc. must be placed on reverse side.) <br /> NEW 'INSTALLATION:' ! /_, i 1 <br /> "iNo sl�ptic tank or seepage pi permitted if public sewer is available within 200 feet,] f <br /> PACKAGE TREATMENT ; <br /> - j' l' ,-S'EPTIC TANK Ilk 3' Size _ <br /> ----- - ----------------- <br /> --Liquid= <br /> ra.pacity_- -- ----- -__ ..T ') o. Compartments-z---- <br /> nee <br /> o p Depth'" <br /> -�. I� <br /> .Type_, -- - ---Matefr€al__.=._ ., t <br /> N en s--=---- <br /> , p span Ee to nearest: Well. m m <br /> art t <br /> -------------- <br /> Lich of each lin - Foundation. Prop. Line - ---=--- ----# �1 <br /> LEACHING LINE' [ ,j No. of Li"nes:,-- -_--- -- --- _. g e.- <br /> f y ! ] --.To of Length.-'-- ---------------- <br /> Box-- i <br /> t <br /> �� y-.._ Type Filter Material - _- <br /> `t1 f-, 1 . Depth Filter Material----------------- <br /> - ----------------------------------- i <br /> ' D,istarace to nearestalVel!-�-,moi-_ ------- Foundation----------=-------- -.Property Line--=------ <br /> SEEPAGE p T� ] De t h.� ----------- <br /> ----- Rock Filled Yes ❑ No E:] <br /> N Water Table:Depth,,-! t <br /> P; .- -- <br /> ' P ------------- -------.Rock SizeF <br /> #; -- <br /> Distance to nearest: Weil....... .�`"- ----------------------­------�- .Foundation------------ <br /> -----------------Prop. Line__.---------'-----------'- <br /> r. ;._ <br /> REPAIR/ADDITION (Prey. Sanitation Permit#. __ .+ ` ` <br /> i - <br /> 1_......._- F.--_.:Date-.---- <br /> Septic Tank (Specify Requir m'erits�}( r - <br /> I <br /> --------------------------=--- - <br /> 1. ---------------- ----------- <br /> -------- <br /> { <br /> Qis`posal Field (Specify Requirements):_...__�D r-_ ^I ------------- - --------- <br /> ' L- = ,t-erg r <br /> ----�------- <br /> : .. ---------------- <br /> --------- -, --------------------------------- <br /> - ----- -- .----- .. - <br /> ------------ <br /> ( F <br /> N (Draw existing and required`a diti^an on river------ ------=-- -------------------------=---- -------- ----- s <br /> ��I " <br /> I hereby certify that I have prepared this application and se si e] . <br /> Ordinances, State Laws, and Rules and Regulations of- the the <br /> J quv nllLocaldHealth Distr ctone in- d Home owneance-with r or <br /> County s <br /> signature certifies the following: ! licensed agents j <br /> "1 certify that in the '111- 1 <br /> peHormbncie of`.the<work for which this permit Is Issued, l shall not a la an <br /> to become subject to Workman s Compensation laws.of Cali or'nits;":'' t p y y person in such manner as <br /> Signed--------- ---- <br /> ----------------------- --.. _ caner <br /> BY ...... <br /> -------------------- --- --------Title <br /> {lf'other than owner] <br /> DEPARTMENT USE ONLY � <br /> APPLICATION ACCEPTED BY_.. A '_ -....... ---- <br /> TEa <br /> i <br /> ---- - -- ------- <br /> --------- ------- - DADIVISION OF LAND NUMBER <br /> - ----- ----- --- -J, _ ----- <br /> ADQ1T1'ONAL COMMENTS-- --- -------- - --------- -:-- �DAT ---- -----------------------= ---- <br /> I <br /> --- --------- ------ ---------------------- ' _ - -- <br /> --- <br /> ------------------------------------------ <br /> -- <br /> ----------- -- � --------- - ----- <br /> - <br /> -------------- -------------- <br /> ------------------------------------------ <br /> , , x„ <br /> _ =-------------------------- <br /> -- ----- - <br /> --- - ----------------------------------------------------------------- <br /> Final ~~ <br /> Ins ection b �'-- - �- - - -- ---- - -- <br /> P Y i _ art <br /> ----- ---Date_ +�r - <br /> EH 13 24 ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F85 71577 REV. 7/76 3M r <br />