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FOR OFFICE USE: '• <br /> FOR FILE USE: � <br /> ��APPLICATION FOR SANITATION PERMIT �7 S/VlS <br /> ------ ---- -------- - Permit No. ,_-_.-- <br /> [Complete in Triplicate] �"" *. r 7 <br /> -------------- <br /> ------ --- -- <br /> -CD Date Issued./.-----"-_ -- <br /> _--------:" This Permit Expires 1 Year From Date Issued <br /> ------------ <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 /> PPT...,..� <br /> rt <br /> JOB ADDRESS/LO TION-._ ----- ---- - ------------------------- s CENSUS <br /> A <br /> _ ENS -------------------- <br /> ---------- . , <br /> Owner's Name =- ----- ----------- <br /> 1%T <br /> -: --- Phone <br /> .0 <br /> �J - - ry --- <br /> `.. Zip <br /> �— _/` � -._ Cit <br /> t <br /> P <br /> . ----- ---- ---- ---- --- .14 <br /> License .#. _�--- �,�-`�;--Phone--'��-/4 S,---- -------------- <br /> Contractor's -• <br /> Name.-;- "{ 'P3---�----'-�----------------------- <br /> Installation will serve: Residence W Apartment House ❑ Commercial ❑ :Trailer Court ❑ -- [ <br /> i Motel ❑ Other----------=----- �°e,, n .. . <br /> Garbage Grinder= = Lot Size--./ `'4e—' _.- -----_ _------ --------- <br /> Number of of living units:__:-"�_,-------Number of bedrooms g - W <br /> i s ,--- - Private <br /> Writer Supply: Public System and name----------------------- r>---------- <br /> clay <br /> - -- .: <br /> - -Pr' e <br /> s P Sand ❑ Silt ❑ Clay ❑ Peat❑Sandy Loam ❑ Clay Loam ❑ <br /> P ❑ O <br /> Character of soil to a depth of 3 feet: <br /> Hardpan Adobe - Fill Material--.._,____"-If-yes, type_`__-"_1'_:`.�"-___"-�----"-- T <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,.etc. must be placed on reverse side.) ' <br /> NEW INSTALLATION: (No septic`tdnk or seepage :pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] <br /> SEPTIC TANK [I' Size--' <br /> t . " Liquid Depth --------------- <br /> t - <br /> - a <br /> Capacity Matrials�=-- ----=------ <br /> -------- <br /> artment <br /> -- -------------- m <br /> Distance to,nearest: Well___ -- Foundation -"" Prop Line___ ---. <br /> i a <br /> No. of Lines ' Length each-,li6e--- Total.= '.. Length ---- - ---- <br /> Tota <br /> LEACHING LINE. [€] - <br /> r <br /> 'D' Box---•------1--Type Filter Material=-------------------Depth Filter Material---`------t---------.------------------- <br /> Distance.to nearest: Wel l----- ------ - ----- Foundation_ -. -'--_" 3_ Property Line- ----------------------- ---. - <br /> SEEPAGE PIT [ ] i Depth--.-;-----------Diameter_._-_. •-----------Number---- ---- --- -- --- -= Rock Filled Yes❑ No ❑ <br /> Water Table Depth--_ <br /> -- -- ---------Rock Size- - -- <br /> :Disfance`to nearest: Well----------------------------------------------Foundation-------- _ --_- "--Prop. Line: <br /> REPAIR/ADDITION (Prev. Sanitation P' mit# ----------------------------- -------- ----Dat ��] � -------- <br /> Septic <br /> Septic Tank (Specif.y Requirements)_-.- -__- ""-- -----------"-�- -� --- --------- - - --- - � <br /> - -- -------- <br /> Dispos Field pecify equirements]- u ------ -- f/ . <br /> = --. --. --- :: , <br /> -- -------------- ----------- ------------ <br /> ------------------- <br /> --- -- - --- <br /> ! <br /> -------------------- <br /> _-""" _ ___-_-"-___""""-___--""".__-..,_______-""_____""""_._.."-"--._-"""_____________________"".__•_--------------------------- � <br /> ., • �e ___--�-__-""�".__.-_______-"__.---.____-_-__-_-.____- <br /> (Draw existing and required add'ition-on reverse side] <br /> i7- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of°the: San Joaquin Local Health District. Home owner or,licensed agents <br /> signature certifies thWfollowing: <br /> f 'f that in the erfo encs»of the work for which this permit is issued, I shall not employ any person in such manneras <br /> "i <br /> certify' p <br /> to become bje t fio . orkma `s C mo pensation.laws of. California." F <br /> t <br /> t . <br /> Signed --- ----- ----- tSS <br /> ------------_ Oweer �p s t <br /> l, <br /> f; <br /> (If other than owner] <br /> ' # -- - FOR DEPARTMENT USONLY <br /> DATE.„' - --�._,,7-'�-- -------- --- <br /> APPLICATION-ACCEPTED B ----------- --------=- <br /> ---- <br /> I DIVISION OF LAND NUMBER - ------" <br /> ------DATE.,_----------- -------------------- ---- <br /> ADDITIONAL COMMENTS--------- ----------- -- ------------------------------------- -----------=--------- <br /> ------- ------------------------ <br /> A - • "------- --------------------- ------------ ------ ------" ___-__.-__.---_ . <br /> _ --------- ----------------------------- -____ _------------------------------ <br /> i .. - -"-"�---"___-_-""____-""__""___--""___-- """_______ ----- <br /> _ _- --- __- ---- <br /> -------__ --- <br /> Finl Inspection b ---------------- <br /> ------------------- <br /> aDd <br /> F&5 21677 REV. 7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />