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FOR OFFICE USE: ~. <br /> APPLICATION FOR SANITATION PERMIT <br /> FOR OFFICE USE: <br /> ----------------------- <br /> --------------- <br /> A <br /> ---------------- D <br /> (Complete in Triplicate) Permit No.,; gyp -___ <br /> -- ---------------- ek <br /> -A Vt <br /> This Permit Expires 1 Year From Date Issued Date Issued-/,,2 <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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: , <br /> JOB ADDRESS/LOCA ON '' 5" H_ ' <br /> -- �'�- - <br /> t-7, ------ --- - - - -CENSUS TRACT <br /> Owner's Name. <br /> Address- <br /> _ = Phone------- - -- -­- <br /> ---- <br /> Name ---- iliar: �, y _ --------- <br /> Contractor's •----------- -- P----------------_ - <br /> 4. 0Z <br /> `` <br /> +City <br /> + sZi <br /> `- ------License # Z. '. � <br /> Installation will serve: - --_ --- e----------------- <br /> C - : ,t f <br /> Residence Apartment;House ❑ Commercial El ,Trailer Court ❑ <br /> f, Motel ❑ Other.__:.--_-- <br /> ---------------- <br /> umber of.living units:___: __Number of.bedrooms--__- Garbage Grinder_--_.__..___Lot.-Size.., _ <br /> Water Su I Public System and'n me- _-: t ----- -- -- - <br /> PP.Y <br /> : . <br /> Character of soil to a depth of 3 feet: Sand --------------------------. <br /> s <br /> � .... aPrivate' <br /> Hard an 't` _. 0. Silt❑ Clay [] Peat❑ Sandy Loam ❑ Clay Loam [7� <br /> P ❑ ; I Adobey❑ Fie!Material Lf se , type '--*'"" _ �-. _ <br /> ` <br /> } <br /> (Plot plan, showing sizeoflot, location! of system in relation to wells, buildings,'etc, must be placed on reverse side.) <br /> NEW INSTALLATION: `(No septic tatlk"or"seepagelpit�permitted if public sewer is avdifpble within 200 feet,} --I <br /> 'o <br /> PACKAGE TREATMENT `S , ..,. "" <br /> j ) SEPTIC TANK j ] siz ------ L_ <br /> � <br /> --- --Liquid Depth.- -_ <br /> Capacity-k._ '_f,>- ._ TYPe -.: Material- ------No. Compartments------ - E <br /> Distance to nearest: Well -- - <br /> Foundation <br /> ! - : --.r-.-. - --.Length --'--- ._ Prop. Line _LEACHING LINE -- _- <br /> . - --- -- -- of each Lina.. ------ <br /> } r <br /> ------- --- <br /> -.Total Length ------- <br /> D. Box_ TYpe�Filtee Materid- 4'!\De---- pth Filter Maa <br /> Distance to nearest: Well-------------- 7- �. . - <br /> Fo ndation.---'----------------- - --Property Line---------------- <br /> SEEPAGE PIT ;. , . b . <br /> Depth---- , <br /> ----Diameter Number_ ; <br /> Rock Filled Ys N <br /> Water Table Dept . . <br /> ° - <br /> Rock Size_ --- <br /> fi <br /> o�❑ <br /> Distance to nearest: Well--'-- ----- `---- <br /> ----- -- Foundatlon-- ------.Prop. Line <br /> P f ------------------- <br /> -------------------------- <br /> ------- lI <br /> REPAIR/ADDITION Prev. Sanitation Permit# :_ ---Date-----;- =--" <br /> Septic Tank Specify Requirements)------ .- -------------------) <br /> f - ... . <br /> Disposal Field.(Specify Requirements)-- . _ _ ------------------------------. _ = <br /> - <br /> ---------- <br /> -------------------------- <br /> ---------------------------- <br /> - <br /> ------------------------------------------ -------------------- -(Draw existing and required adclifi'ionon-reverse'side}; '� <br /> 1 hereby certify that 1. <br /> .1 have prepared this application and that the work will be done 'in•-accordance with San-Joaquin <br /> Ordinances, State Laws; and Rules and Regulations of the San Joaquin Local Health District, Horne owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performcince of the work for which this permit is issued I shall not em to an q <br /> to become subject to Workinan's. Compensation laws of California." P Y Y person in such manner as <br /> ig <br /> l <br /> S ned <br /> L <br /> BY------------------------------------- <br /> - - <br /> - - ;- Title- <br /> ' {If other-'than owner) .- - -- <br /> = <br /> FOR )IMPARTMENT LISE ONLY t <br /> APPLICATION A(CEPTED•BY­-_-__.� _..__�- , Y ` <br /> Z_ t „�; � <br /> DIVISION OF LAND NUMBER... = ------ - _----- --------DATE:.--1-- - <br /> -- -- -- -------- <br /> - ------- - ._ - - -------------- <br /> ADDITIONAL1 <br /> COMMENTS ---------------- <br /> DATE --------- :--- ------- -- <br /> ---- -- <br /> == . <br /> --------------------------------------- ------- <br /> -- - <br /> ------------- <br /> Final-Inspection,b <br /> - ------------------------------------- <br /> / <br /> ------ ------------ <br /> --- <br /> - - ---- - --------- 'Date...-'�-Z..�'_- <br /> EH 13 24 . _. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677-REV. 7.176 3-M <br />