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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -----------------.. <br /> (Complete in Triplicate) Permit No..�. :lD S <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 001pance No. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOVATO .. ..... -------- -------C .. ...................` <br /> ..-�. -- - - ---------CENSUS TRACT------------------- <br /> -- <br /> Owner's Name <br /> -- <br /> .._ •--••----.c�-_a__�c,....-. -- --- .......... ..: -• :--._. -Phone.-`I..------•--•-• - -----Address.. <br /> .......r S -Q <br /> r .. . ...............City-----..... - ---- ------ iP� ... . ----- <br /> Contractor's Name..---- License #_/il <br /> he <br /> Installation will serves z Reside ce p ent House ❑ Commercial ❑ urs <br /> Motel ❑ Ot <br /> . - h —Number of living units: _......_ •_.- er of bedroorTis_ orge Grin :__-.--..............Water Supply: Public System and name-- "�' - ----------- .-----....._:__,....._ Private ❑�,Character of soil to a depth of 3 feet: San Silt{] CSI ❑ Peat ❑ Sandylay Loam ❑ <br /> }*" / <br /> Hardpan ❑ Adobe f Material - = if Yes, type----- - -------- <br /> (Plot plan, showing size of lot, local on•�o�f system innr4e tion two we,il buildings, et•. must be placed on reverse side.( p` <br /> NEW INSTALLATION: (No septic tank ar seepage p,lt rmitty p�?blic se er is avail/able within 200 #eet,) N <br /> PACKAGE TREATMENT ( ] SEPTIC TANK <br /> - .Si d.....__..... --------`------ ----------------- - - ._...._Liquid Depth.'--Y--- <br /> - <br /> Capacity- 1_b.. TYPat" 1, 1- :C CLt' /No. Compartments ---------- <br /> Distance ------ <br /> to nearest: Well-`-__ _...� 11-.._ ` ..Foundatio, Prop. Line......... ............ <br /> LINE ( No. of:,Lines -- --- -- ---------------Len• hof eac li :_ .-- Total Length -------- ----------------x-- <br /> LEACH ING _ <br /> D' Box. -- - - Type Filter MaterialSf� G � t. Filfier�Material-- -----.�.�---- ------------------------------------..:----.. <br /> ,r �. <br /> Distance to nearest: Well--- - <br /> -a0© unddtin- =------------------------Property Line.------... <br /> SEEPAGE PIT ( ) Depth............-----Diameter..___.------- _...._Nu be ----- Rock Filled Yes E_ No ❑ <br /> Water Table Depth--------------- R ---- <br /> Distance to nearest: Well --__ -__.______ -__ ounclation'1�.._.... ......Prop. Line_....----------...._. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------- ----------- -- ----.....---Dated... .. ...----- :---------------__-) <br /> Septic Tank (Specify Requirements)---- ---------------- - ----•-- ....... .. _. ...._. .... <br /> Disposal Field (Specify Requirements]------- --- -------- - ..__..._-.-:._.._.._-` +... ------- - ........ <br /> .... ---- --- ---- --------------------------- -- - ................. .................. <br /> - <br /> ------•-------- <br /> ----------- --,-.--,: -- - - •------- - -------------- -. .. -- ---------- ---............. <br /> (Draw existing ,an d required addition on reverseside]"�-"- <br /> I hereby certify that I have prepared this applicapttiCnand that the work will be done in accordance with an .ba yin County <br /> Ordinances, State Laws, and Rules and-Regul&tlas of the San Joaquin-Local Health District. Home ownere""n'�or�#icsed agents <br /> signature certifies the following: <br /> "A certify that in the performance of the wo�rrkf for which this permit is issued, I shall not employ any person in such manner as <br /> to become suhjec t Workman's pen/tion lows iof California." <br /> Signed. ...............Owner <br /> By.........................- ---------- -----.Title ---- ........ ----------- .,..... <br /> (If other than owner) <br /> R EPARTM N3 USE ONLY <br /> APPLICATION ACCEPTED BY.-: ------...._DATE --- ----- .. ..� ........ ..... <br /> ------ ----- ---- --- -- ----------- <br /> DIVISION OF LAND NUMBER........................ -DATE.-------------------......:........... <br /> ADDITIONAL COMMENTS......... ............. .. . . -------- --------- • ------- --- ----- .... ...... <br /> _-----------------------------________________________'...---------------------------........................-____ __.-----------------------------------------------------.-------....................... <br /> -.._..... <br /> Eli -- 2- y- - - .--- t_'`. ... ---------- ----------------- --- ----------------------'----------- --------- ----------- -- --------- -------- ---- <br /> Final lnspectlon b -------------Date- - ---- -- ---. ..... - ---...-...----- <br /> SAN JOAQUIN LOCAL H LTM DISTRICT F&5 21G77 REV. 7/76 3M <br />