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FOR OFFICE USE. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete Jnjriplicate) Permit No <br /> ----------------------------------------------------- --- <br /> Date Issued-- ---2 _---7 <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 applicationlis made in compliance with County OrcUnance No. 549 and existing Rules and Regulations: <br /> .,.....-.�+c(./mss.-.n,a�. �T�,.�..�. �p:.�—.— .'•..ww—r = �- <br /> ' C�Q S i e __-_____._ <br /> JOB ADDRESS/LOCAT fl --__' ' I ' <br /> �6 ' _ - - . ------- CENSUS TRACT_.._._. --------------- <br /> Owner's Name --.---- - ----- Phone---- <br /> - <br /> ` ----- -- <br /> Address- - -- ----- -- ---------- ---- --- - ---------- <br /> h <br /> --- -- ----------------- <br /> Installation' <br /> - ----------- City s [--'Zip <br /> ti±.. . } <br /> Contractors Naine_ - Apartment House. � Commercial #��a�S Court Phone______________ ��1 _'___- <br /> Installation will serve: Residence p ❑ ❑ ❑ [ ` <br /> s Motel- Other p. ' •-• s <br /> �/ �-- <br /> Number of living units: --.1--_ --_Number of,bed . oms_:_.j .Garbage Grinder _- . ..__Lot�Size ..-�-._-- x --_ --------------- <br /> Water Supply: Public System-and name----- <br /> ,-- i ---I----:-- -:-- `----------------------------------- -- -- ..----.- -------Private <br /> p ❑ ❑ ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Character of soil'.to a depth of 3 feet: Sand Silt ClCIa ' Peat S f <br /> Hardpan❑ Adobe Fill Ma ❑ <br /> l <br /> F terial_.._-'.._-__�f es, type... <br /> (Plot plan, showing size of lot, location ation of,sys;emyin relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No°septic tank or seepIt age ;pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ['j Size------------- ....... '_ ---Liquid Depth.:------.---.-----_-----. <br /> i i <br /> Capacity=--- Type Material" - --3`...No--Crompartmen#s--------------------------------- <br /> Distance,to nearest. Well:__.___.._ -_ ___Foundation------------------ Prop. Line., .- __----._---.--.---. <br /> LEA�CHI -- No. of Lines--------- �__ --__._. -. <br /> INNIG LINE <br /> Lengt. f each . ------------------.'i..__. 7-ota <br /> l Length. - - 4 <br /> D Sox !--Type Filter Materia ------ ----.Depth Filter Material__'•--- ----------------------------------- <br /> --- <br /> ancato neo Well- n--ation_---- ..................... Property Line-- ----------------------------l-- <br /> SEEPAGE PIT DepthDiameter,-,------- --=------ Number_ ' <br /> Rock Filled Yes ❑ No <br /> ` l? ------------------------------Rock Size----- ---------- f <br /> f Distance to nearest-.lWell r <br /> Water Table <br /> Foundation„- - } -.Prop. Line <br /> REPAIR/ADDITION (Prev, Sanitation Permit#--------- -------- -- -----------------------------Date------------- ---------- -- ?---- -__-) <br /> Septic Tank (Specify Requirements)_---_ '� - -� _ -, � ---' - --- - - ----------------------'---— - --- ----------------------------- <br /> Dispo <br /> - ---_-- <br /> Disposal Field (Specify equirements) �« <br /> ------------- - -- .__-._ - ------ ---_______ <br /> ' - <br /> (Draw existing and required addition on reverse side) { <br /> k <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 Regula_.tions of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: : <br /> "I certify that in the performance of the'work for which this permit is issued, )-shall not employ any. person in such manner as <br /> to becom� biect to rkma�sCompensation;­ICWS.r of California.".. S. <br /> Signed-- ---- <br /> -.-.-------- Owner <br /> By-1 <br /> g �� cd/ { <br /> BY - ------- - -Title--- _ <br /> '` i <br /> (If other than owned k <br /> FOR DEPARTMENT USE ONLY: ? <br /> APPLICATION ACCEPTED BY----- ' 1 -----------. -- -- DATE. ' <br /> DIVISION OF LAND NUMBER ---- -------------- -----__ : .:: =------------------------------------ ------:-------DATE ---_-------------- ------------- -- -------- <br /> ADDITIONAL COMMENTS-------------------------- ------------------------------------------------------ ---------------- - <br /> ----------------------------------------- -------------------- --------------------------------------- ---- -------------------------------------------- <br /> { ----- ------ ----------- --- ---------------------------=---- -----------------------------`--------- ----------------------------- <br /> --------------------------- ------------------ -_-- --c---- <br /> Y= = Date = ' -._..._ <br /> Final Inspection,b I, -----` -- �" �_--"=----------------------- --- - ------------- --------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV. 7/76 3M <br />