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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) Permit No.7 __14sy <br /> r, <br /> This Permit Expires 1 Year From-Dat Issued Date Issued-/ ,f -_7 <br /> i <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 /> _ <br /> JOB ADDRESS/LOCATION =- ' y CENSUS TRACT a <br /> -- -- <br /> Owner's Name-- <br /> -- Phone--c �����ar` y <br /> Address // ---L... -- L= - Cit zip - <br /> =F <br /> Contractors Name_. e_ ` _ - -------License #_. 7-2-�l----Phone---- --- __Installation will serve: y Residence E�-- Apartment House.❑ Commercial ❑ Trailer Court❑ <br /> ....].... -i• Motel ❑ `Other--- <br /> Number of bedrooms ---.Garba a Grindex-_- ------_Lot Size <br /> -.-. <br /> -=---Number of living units:--:---/`__-_-- <br /> # <br /> Writer Supply: Public System and name------------------ _-----,:--------- - ---_._---------------.-------.---------------=------------------------------------ Private <br /> Character of soil to a depth of 3 feet: Sand 0 .Silt 0 -.Clay ❑, Peat❑. :Sandy Loam [ Clay Loam [+ t <br /> Hardpan ❑ : Adobe❑ FiU Material-.--._-..:._If yes, type____________ <br /> R ------_------- <br /> ._."-. <br /> A � �f l <br /> (Plot plan, showing size of lot,llocation of system in relation to!wells, buildings,-etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No� septic tank or seepage,pit perm'*6d if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] s SEPTIC-TANK 1 rA i <br /> F Liquid Depth. ----------'------- <br /> [ 1 Size - '-- -- - ----- '� - <br /> Capacity i Type : 'v1 :... . -Material = = No. Compartments = <br /> . . Distance,to neareit:Wella <br /> ' Foundation Prop. Line. � <br /> ..: -_.... 4. � ----� 4 Fou datio _� - .. -.-. P o e... <br /> LEACHING LINE_ _ <br /> [ ] NDo.g�f Lines - T e Filter Mateeagth of each ''De -th Filter Material= Total Length------------------------------+------- -- S E <br /> YP .. :v. E p s --------- -- - - <br /> Distances to nearest: Well-------------------q- _Fou.ndation--------------------------------Property Line--_------:------:---------------- <br /> SEEPAGE PIT [ j Depth----____________Diameter_•........ --------Number-------------------------------- "4 Rock Filled ; Yes El No ❑ t <br /> Water Table-Depth_._;. ^ `--------r -------- Rock Size-------`--------------------- <br /> -------------------- <br /> V1 _ 3 <br /> ( t*� r <br /> - - .. ..�.. 3--..f - -. <br /> • ----------•------- <br /> --5--:--- .Foundation. ---------- = Prop; Line------------------------ ----- <br /> REPAIR ADDITION (Prev. Pamit#-------------- <br /> P ---- ----- ---- �'' - ---------------------------- <br /> Septic <br /> - <br /> / at :.� <br /> Se ptic Tank (Specify Requirements)--- -- --'-- =�r ------------------------------------------------------ <br /> Disposal <br /> Y <br /> Dis osal Field S cif Re uirements _ __ .____._ <br /> � or <br /> � / 3 � _. <br /> -------------------------- ----------- --------------- 1, <br /> _ y ° a . <br /> f ----------------- ---------------- -- ---- -------- ------------------------- ---- ---------------------- <br /> (Draw existing and required addifion on•reverse side)-r-- -- -, <br /> I hereby certify that'l have prepared this application and.that the work\will;be done in accordance with Son- Joaquin'County <br /> Ordinances,, State Laws, and Rules and Regulations of: the; San Joaquikiocal Health District_, Home owner or licensed agents 3 <br /> signature certifies the following; 71 <br /> "I certify that in the performance of=the work..fo'r-which this permit is issued I shall nor employ ally person in such manner as <br /> to become subject to Workman's .Compensation tows/Of_ California.'.' 1 <br /> Signed , - -- --- --- ----- -- -- ----Owner - r <br /> BY- --- ------ -- ----------------------------------------------------Title.......---- ------ L1f - <br /> (If"other than`owner) <br /> { FOR`DEPARTME T USE ONLY . <br /> APPLICATION ACCEPTED. BY--- - -------- ---------------'--------- - DATE. •-.7 i <br /> DIVISION OF LAND NUMBER-------------------- ---- - --- --- <br /> -- DATE-----------------. ----------------- <br /> ADDITIONAL COMMENTS------------------------------------- -------------------- .......... . - <br /> ----------------------------------------- --- --- -------------------------------------------------------------------------------- ------------------------------------------------------------------------ <br /> --:-----------:-------------------------------------- - ---------------- - ---; -- --------- - ---- -- -----------------------­------------------- ---- -- --=--- <br /> ----------------------------- - •--•- -• - _----_------------ ---- - --f/----------------------- <br /> Final <br /> ---_--•----•-• --- <br /> Final.:.Inspectlon'by =� _- _=� ==-=------------ ` = Date /_._,_.. <br /> EH 13 24 , SAN JOAQUIN LOCAL HEALTH DISTRICT F8S 21677 REV. 7176 3M <br />