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,3-"'FOR OFFICE USE: � � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ` - - <br /> (complete in Triplicate} ,. Permit No.___7 ------ ----- <br /> Date issued._"'_ <br /> _____________ ____ This Permit Expires 1 Year From Date Issued '"- <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/f OCATION. . , 54 54 4,i:k7 _-- <br /> I I f 111 or <br /> Owner'is Name. _ e <br /> t - - hon <br /> } � _r►,�� cog P �?��"`�l�o <br /> Address------------ . _ jyvTe%-� City �1.J ZAPS <br /> Contractor's Name.__.__ 1- � (1 �.. - ° Licen #-' ki-� ----Phone_ ___--------------------- <br /> se <br /> ,.... ,.... Motel Other - _- <br /> --= s <br /> Installation"will serve: Residence Apartment House Commercial Trailer Court E] <br /> Number.of living units_______ ________Number of.bedrooms.___.3---Garbage Grinder____ ':Lot,Size-_•,;._ ------ -- ------ ------I- ------------------ <br /> Water Supply: Public System and.name---------------- . =------=---- -------- ----'--------- --- -----: :----------------- --------------------------- :-Private [R <br /> a' <br /> Character of soil-to a depth of 3 feet: ' Sand ❑ '.Silt 0 Clay ❑ 1 Peat❑ Sandy Loam ❑ Clay Loam 3 <br /> ' Hard an Adobe terial___ -.--__-if es, e___:___--- <br /> o p ❑ Q Fill Ma Y type <br /> [Plot pl�n, showing size of lot, location of system in relation to wells, buildings, etc. .must be placed on reverse side.] 0 <br /> NEW INSTALLATION: �?. septic t.a.nk or s'eiepage ,P�it permitted if public' sewer'is available within 200 feet,]' <br /> REATMENT—[ ]' ' SEPTIC-TANK [ ] Size_______ ___x_ _u_'o______________________Liquid Depth,___15'Y�______-- <br /> PACKAGE T. Ca pacit l "O_ .__T e ,<i� G�/___Material_--'':-__--------------- -No. Compartments--------t --------------------- <br /> _Distance <br /> ------ ---------- <br /> M...'Distance to nearest: Well. 3___________ ______________Foundation_' 0__=_-:-_________Prop. Line�_._.___.__.__.__ <br /> --------- <br /> iTi_LEACHING LINE f J No. of Lines Length of each line ,r/ __________._.___ i1 <br /> 9 : ` a, <br /> ' f� -----,Total Length.: f <br /> </ <br /> ] D' Box_.__1----;._T e Filter Material_��¢X .Depth Filter Material------- <br /> A . _ _ <br /> t <br /> YP / . I ! r . . �., . <br /> Distance to nearest: Well___ _ --Foundation---- -_--_-____Property Line._:__' }____._____________________ <br /> SEEPAGE PIT [ ] Depth_____ ________Diameter - Number --- 0\a, �bock Filled Yes❑ No E]. <br /> r Water Table.Depth- ---------------------------------' ` - Roc� ize-___-.:_ ---`---------- --- . <br /> ------------ ., <br /> Distance to nearest: Well------------------- ------------t� Foun�on--=------._----- _ ly?rop. Line_:--------------- ` <br /> � k E <br /> REPAIR%ADDITION (Prey:Sanitation Permit#_..__: �___ _______ , ..N___[: Date_.�l.'� �`--___; --- ----- <br /> Septic Tank!(Specify.Requirements) � = = r <br /> �.�. = <br /> Pt ld,,(Spe�R a+ir entsI.....---- ---�..,�-- �------------------ -----------�-`------------=--------------------:----------- ------=------ ----------- <br /> Dis osd FOe - 't ��` ----------- ` = = <br /> --- ---- ------ �- ------- <br />,. I----------- ---- -------------- ---- -- ------ - - ---------------------------------q ------------------------------------------------------1 -'---------------- ------------- <br /> (Draw existingarid required addition ori reverse side) ��� l <br /> hereby certify that I ha ,e-prepaJed-this-application-and-thd the work will be � ne--in. accordance with Sad: Joaquin County <br /> Ordinances,. .State Laws,t and Rules and Regulations of.the San Joaquin Local Health District. Home owner o licensed agents <br /> signature certifies.the following: r <br /> l <br /> "I certify that'in the perf�rmanc of the work for which'this permit is issued, I shall not employ any person ini such-manner as <br /> to became sub'ectZ­__ <br /> orkm n Compensation laws of California.". A <br /> I s <br /> I - t <br /> Signed ------- �L G�'-- -------------------- -'---------------Owhar <br /> B -------�-------•---------- ------- ------------f---=- =-------------------------------------_-- ----- -Title --- <br /> --------------------------- - - - ---;- l <br /> (If other than :owner) <br /> O <br /> FOR DEPART ENT USE'ONLY <br /> 4PPLIC�TION ACCEPTEDIBY=---= ---- ='---- --- ------ <br /> ---------------------------------------------DATE._ Y _... <br /> DIVISION OF LAND NUMBER------I--------------------=------ ------------- ---------=-- ---- ------------------------------------DATE.--------.------ ----- -------- <br /> ADD' NAL COMMENTS------------=�....` ----- ------------ --------------------------- <br /> �.. <br /> F f - ----------------------------------------------------------- <br /> ---_ ------- <br /> - r - _ ___ �--------______ _____ <br /> I Final Inspection by:- R - F - -- ------Date.---- dCJ�� - •-----=-----•------- <br /> I <br /> EH 13 24 SAN J QUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 776 3M <br />