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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT a1ssued_._,;?-"�--_- <br /> E: <br /> ----------------- -1----------- <br /> -------- -------- (Complete in Triplicate) <br /> ••-------------- ------ -- ---- - ------- ------ This Permit Expires 1 Year From Date Issued -_2� <br /> Application is hereby made to the San Joagu n Local3Health Disfirict for`a permit to construct and'install the work herein <br /> This application is made in compliance with County Ordinanc Ngo5gq a 4d existing Rules an`d`Regulations: described. <br /> JOB ADDRESS/L 10 Lz, <br /> arae. .---.0 US TRACT.--- -Owner's N �. -h EN- �a1ti f.r Ph• - � ..- - - ----- -- - - --- _Address one --- -------- -- --. t ;, T ; <br /> Contractor's Name--- -- h��.. :-.----- ----------------- ------ - -- -------------------- <br /> -- - f i Zip--- <br /> Contractor's - <br /> _.p. r -Lce a #'_ r].�.---�- __P on �- .�___�_� <br /> Installation will-serve: Residence _-A_pcirt enHouse ❑ Commercral � Trail ` <br /> h e <br /> �' ;.%.. -Trailer Court <br /> .1. Motel �_ '-__ v . i. . <br /> r Other Is <br /> r 3 S; <br /> Nu' <br /> mber.of.living units:: �_ _: __ __Number of'bed omni Garbage Gri der_ ---,Lot--Size.__._,- -_(/1,�_% <br /> ' 1 �� € - - - <br /> Water Supply: Public System:and name__ -__. .__ t ' <br /> Character'.0 soi to p h of 3 feet: : Sand. S• r°' t Pri <br /> r ;- -- 'vate' <br /> r .1 . ❑ vCIO,Y ❑ I Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material__.._d� _V <br /> yes, type --------- <br /> ----------- <br /> (Plot plan, thowing size .of Ibt, location of system n relation to`wells,!buildings, etc.tmust be placed on reverse 7sideJNEW INSTALLATION: '` ' ( #" ., s. ��,'(No septic tank'or-seepage plf permitted ifpubli� sewer is jaildble�ithin 200 deetPACKAGE TREATlv1ENT [' ] SEPTIC TANK ` _ i t,I : ---::-: ,i uid Dep _,.- --------- <br /> Ca acit C) _ Jt <br /> € <br /> p Y ,Types" / Materi I_ p rtm . <br /> 1 �Y <br /> -No. Cam a e ts�'- f <br /> h 1 tante to.neare.st:,Wel1_'� gra : ' Q - �v <br /> t C,31 Foundon -= - --- Prop. Line' <br /> LEACHING LINE [ .No-.-of,L•ines_,_ Lengt - f,eac Irne'i-- ,�� ( �{'- <br /> �� { <br /> D' Box_ Type Fi1teh Mciterial: <br /> �t �, ..�-f..._./:;i.o..m..eNter• <br /> --=- . -----!_ <br /> -!.Depth nF <br /> ,i,lter-Mater-F ia/l <br /> --------- <br /> -_ <br /> �f <br /> � - <br /> stanc nearest: 4 11 ; : oun aio <br /> Property LineEPAGE PIT ------------------------- <br /> SE <br /> t <br /> -------- umber <br /> - t --- filled - Yes <br /> 1 Water Table.Depth._ '� c Si <br /> �k�( o(❑ <br /> t Di r / i - ----- <br /> v <br /> Rok5• e __ - ,T- k <br /> stance.to nearesf:WeI1__-�_--/: _ _ j " T f ' ' [? <br /> -----:.--- ' <br /> Foundation --- ---- ...............Prop. L"rne------ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_.f_ _1__:_ »____ r _ -- <br /> Date - - _ <br /> Septic Tank (Specify-Require s)------_"`` _• � i f } <br /> isposal Field (Specify Requirements)__._._- _r--:--- f , ( <br /> - h <br /> --------------------------- ---------------------------------- <br /> -------------------------------------------- -- <br /> --- ------- -- ---- - <br /> ---- ----- # <br /> . _ .. -- - ---------------------------------------------.. <br /> -------------- ---------------------------- ------------------------------------------- <br /> (Draw existing and required addition on reverse side) ' <br /> I hereby certify that I have prepared this.application cnd that the work will be done in accordance with San Joaquin County t <br /> Ordinances, State Laws, and Rules.and Regulations of; the San Joaquin Local Health District, Florae owner or licensed agents R i <br /> signature certifies the following: : w <br /> "I certify that in the performance of,the work for which this permitiis issued, I shall not employ an ¢ <br /> to become subject to-Workman's Compensation favus of California.- <br /> Signed <br /> Y Y person in such manner ps P <br /> Signed - ----- -----'- ---------------------Title---------_--- Owner <br /> BY k <br /> j <br /> _ <br /> (If other than owner) ; <br /> 'FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_________ _- = <br /> -------------------------- <br /> --- ------------ DATE. { - ---- -- <br /> DIVISION OF LAND NUMBER------- --- <br /> ------------ _ <br /> ---------- --------------------------- ---------------. <br /> ---------------- DATE <br /> ADDITIONAL COMMENTS... - ------------ --:-:---- ----------- <br /> ' ---------------------- -- ---------- -- --------------------- -- ---- <br /> -----=-------- - <br /> _-____ ___________________________________ <br /> _ - ___________________________________________________________________________________________________________________________________________________ <br /> ____________ ----------------------________________________________________________________________ .__._. __ <br /> Final-Inspection by-------- --- ��. -------- --------s---- <br /> ------------------------------- <br /> Date.- <br /> SAN <br /> ---------------- <br /> Date- <br /> EH 13 �a SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />