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r � <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION ICOR SANITATION PERMIT <br /> (Complete.in Triplicate) Permit No.__'7j_'_1_7-.__ <br /> ` -------------✓\ F <br /> Date <br /> • ••---------------------------------------------------- Thi;s Issued_..3" _6".7 <br /> Perrrit'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 Orciinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION..-- <br /> CT <br /> 1.-_.-.. ��--.----_-- <br /> ;----CEN TRA <br /> ------------S_- <br /> •- -------- - -- <br /> - <br /> Owner's Name--- Phone-- <br /> Address <br /> ---------------- -----one <br /> Address----- ----- -- --- -�� - - ..:City— - --- --- ---- - --� - -z'p--�---- --.----------- ---- <br /> �Contractor s Name -------- r License y ----Pho ----- <br /> -------------- <br /> Installation <br /> - <br /> •-.- _ <br /> InstallationAwill serve: Residence Apartment House'❑ .Commercial ❑ Trailer Court ❑ <br /> Motel ❑ - <br /> Number-of.living units:__- --------Number'of bedrooms-.k;Z-__-Garbage Grinder_-------`-Lot.Size---I `-� ` <br /> Water Supply: Public System'andiname-------------------------------- 7&Ak :::_.- _-:------- - ----------------- ------- --Private El <br /> 1 <br /> Character of soil to a depth of 3 feet: : Sand ❑ Silt El Clay ❑ ' Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> s Har pan Adobe Fill Material-.._. _ - " <br /> ❑ ----If yes, type------ <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 tank-or seepage`pit:permitted if public sewer is available within 200 feet,) t <br /> PACKAGE TREATMENT1 X t <br /> N[ ] -SEPTIC TANK, [ ] r Size-- t --------------------------i------Liquid Depth--------------------------- <br /> Capacity p Y "--------------Type- =a = Material `------=-- --'-- .__No. Compartments.-: <br /> ------------------ <br /> ;. Distance .to nearest: Well--------` ------` e------ Foundation.------. ,.= _. ---,.Prop. Line.---------------------------- <br /> l <br /> LEAC. HING LINE t No.B XLines- � -- ----:.-.----Lines-.- <br /> Length otf eac.h line.-'-- ---- <br /> og---- ---- -_ . , „ , -------------,------------ ----- <br /> D .._T Pe Filter Material -.--__'.-----:---..Depth Filter Material------------------ <br /> i_:--- - ----+-------------- - ------- <br /> SEEPAG Distance to nee est'1Nell Foundation_-.:--_ - -.__.Property Line <br /> t -------------------- <br /> E PIT [ ] Depth. -_.Diameter1 � .-._Number _:_- -------------- -- � Rock Filled Yes ❑ No ❑ <br /> Water_Table Depth---=-- =-------------------------= -------------.----Rock'Size-------= <br /> €✓J Distance to nearesf:Well-?-----. ------:-------------'-----_,-------Foundation ---------------=---------Prop. Line--------_------------- <br /> REPAIR/ADDITION (Prev: Sani t 'on Per i.t#__:____ - --------------------- ______ Date___-_____- - <br /> - <br /> r. <br /> Se tic Tank S edf Re uirem r(itls lam°t <br /> p I p Y q [ <br /> .LL <br /> Disposal.Field (Sp ecify�Requirements)--------------=----= - = - `' f -° <br /> ----- <br /> i h _ ,- <br /> ----------- ------ - --- - t I <br /> - -- <br /> . <br /> {Drawezisfind'and required addition'on'reverse side) <br /> I herebyy certify that'l have prelp <br /> ared this application-and that the-:work -will be done Tin accordance with San Joaquin,County <br /> Ordinances, State Laws; andRules_ 'and Regulations 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, I'sholl 'not employ any person in such manner cis <br /> to becobject .to Wor� Mdn's, Compensation-laws of -California.' <br /> Signed-: -- - : - - :-..Owner= <br /> _.. <br /> I. <br /> By! .a�� <br /> --------- -,- �tle' T' Y <br /> (If other`than i`ownaf} <br /> ORS PEPART AENTUSE ONLY— <br /> APPLICATION <br /> NLY"APPLICATION ACCEPTED BY-i_ - ------=--- --------------------- ----------- DATE-----3 ¢> <br /> DIVISION OF LAND NUMBER. --- -.:------------------------ -- ---------------- ---- - ------ -----'----------DATE. -------------------------- -- <br /> ADDITIONAL COMMENTS ----------------------------------- _------- <br /> ! .. .. --- - ------------ -. <br /> - <br /> -- _ __ <br /> ___________________ _ <br /> �-_... r-. ------------------------------------ ----- -------------------------------------------------- <br /> Final,Inspection by:_.- _. _.�� ._ ._ .. ----- Date �_� ----------------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7176 3M <br />