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FOR OFFICE USE: FOR OFFICE USE: <br /> ` APPLICATION FOR SANITATION PERMIT <br /> --------------------------- Permit <br /> - --------------- <br /> (Complete in Triplicate) <br /> i • Date lssued10-,3/--!: 7p'' <br /> r�-- ----------------� ---i-.-- ------ -__-..-.-._. This Permit Expires 1 Year From Date lss'ued <br /> v <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> Fw, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> _ _ �. -- - � —,.,.•,-�. - • - - .. <br /> JOB ADDRESS/LOCA ON._�J_-7 ti"�•--------------------- '-- <br /> --- TR <br /> Owner's Name --- - ` Phone-- <br /> Address. <br /> ne C. <br /> CENSUS _ <br /> ------------------------ ------------Pho - — - <br /> Address.. ` � -------------------- - --- :-- � Y <br /> Cit ---- , - --------------zip --------------------- <br /> Contractor's Name._ �-�-- License # __. 7__. ------Phone._:-_. ....... <br /> f <br /> Installation will serve: ResidenceApartment House.❑ Commercial ❑ Trailer Court ❑ <br /> - = , <br /> •�• -r-- -l• Motel �_ Gc�rba e.Grinderr.-�--------Lot i <br /> ❑.. : Other - - - - <br /> Number of living units------- ------- Number of,bedrooms_-- _-___- g Size.-._�_-�-'-���------_-=._--.----,--------:--- <br /> Water Supply: Public System and`name----------- <br /> '7 -=----------=---- = -------- ---------------------------------- - -------------- <br /> -Private �c]� <br /> Character of soil to a depth of 3 feet: Sand 0 'Silt Clay El Peat E _ Sandy Loam Clay Loam [ 1 <br /> r Hardpan E:] Adobe:❑ Fill Material--..__;-----_If yes, type-- .------ t ; <br /> (Plot plan, showing size of lot, location ofyste`min relation to_wells, buildings,,etc. must be placed on reverse side.) ' <br /> NEW INSTALLATION- (No•septic tank or see age 'pli'perm--itted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ J' ' SEPTIC-TANK �� Size <br /> [� `S� �_� --------Liquid Depth-'...- <br /> Capacity_. :Type :.+,_�., -MatexiaSlk '!�- ' ------._-No. Compartments-- --� -------------- <br /> /(9 <br /> Distanceao nearest:.WeII__, � r_____________ Foundation:_,_ �__----------Prop. Line.. --------- <br /> f <br /> LEACHING LINE [ No. of Lines -�r_ __,Leng �o�frea irie..` _�,__--_ ......Total Lengthf--_ �-� i <br /> D' Box ._.,Y�' PFilterr /` f' <br /> /e?t T e alter Material �_lrl���De th Material . -_-_� t_ <br /> --- -------- - Ftoundation__._____-- Property = I <br /> # .r € i � {- € <br /> me <br /> l Distance to nearest.Well�ll_`� ��. � /�, - � ; <br /> SEEPAGE PIT [�-}� Depth-.,?,S i .D:iameter._ -----------.i Number+._ -----.--- (tockilled.'Yes� No <br /> Water Table'D`e•pth ------f----- ` c . .Rock Size---------------- x [ ------------ -•� <br /> i Distance.to nearesf;"Well '-_ _., • _'Fou ion _Y� r_-.Prdp, Line _�� , <br /> « ' ndat' ---� - ------- <br /> Prev. Sanitation Permit#__ - ., <br /> (Prev.( _✓ `Date ---------- <br /> REPAIR/ADDITION ) <br /> Septic Tank [Specify Requirements]_-__= 1= 1 � ° <br /> _ M <br /> i Disposal Field (Specify Requirements)' - -.-_------------ -------------------- = 4 --------------------------- _ <br /> ---- - --- <br /> ------------------------------- <br /> --=--------- ---------------------- <br /> i r -------- . <br /> --- ------------------------------------ --- . , <br /> 1 <br /> P done in aLCI - <br /> a I <br /> (Dr`awexistingandr;equiredadd'efiononreverse sideI hereby certify that 1 have pre ared this application and that the-work rwil ;be�� \ ance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the; San Joaquin locfl,Heal h DistricN fFlo#me o owner or. licensed agents <br /> signature certifies the following: a ! <br /> "il ceitify that in the performbHce of the work for; which this ermit ism issued, .I shall�nof�nployn fij person in such manner as <br /> g s of California.".. <br /> - - - ---- --- -- + <br /> to become. subject to. Workman's. Compensation'law :Owner <br /> I <br /> B I �,; <br /> � <br /> - Title.__. <br /> Si ned = � ` <br /> Y = <br /> . other t an owner) ! <br /> FOR DEPARTMENT USE 0141Y; f1,1 <br /> APPLICATION ACCEPTED'BY.:,. -------------.---- ' j------ --DATE ' =��-Q ---------=--- <br /> ADDITIONAL COMMENTS = - ------------ DATE --------------------------- <br /> ------------ <br /> - = <br /> DIVISION OF LAND NUMBER._..------------------------------::-:---__ <br /> ----------------------------- - ---- -----------:------------------------- --- -------- ---- -------------------- -------------------- ----------- - --------------------------------------I.... <br /> ----------------- -------- ------------------------------------------------------------ <br /> ------- <br /> --------------------------------------- -------- <br /> Final Inspection by: �a[� �1(l �/ Y Rate - <br /> _ � 1L <br /> -- (.,- - - <br /> 6H.:13 24 II SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br /> z ', <br />