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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT d <br /> Permit No.__7 --�T -- <br /> --------------------------------------------------------- (Complete in Triplicate) _ <br /> ------------------------- Date Issued.1 '7 <br /> ------------------------ <br /> --------------------------- <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 compliarice with,Eoungr Ordinance No. 549 and existing Rules and Regulations: <br /> a_` -- <br /> } ---- <br /> CENSlJS�f$ACT.___.-.- ------- <br /> JOB ADDR ----------------- <br /> ESS/LOCATION,.... <br /> r Phone <br /> Owners Name--.-__"..---------- <br /> Address_ ` City /6 h` c�` .�'. <br /> ----- - <br /> F G rC� _! � ----- ------------------License'# r - <br /> cP one <br /> Contractor'shame_____._---�----------- - <br /> Installation will:serve: Residence ❑; Apartment House. Commercial © TraalerICou F-1 + <br /> r .. .. .. Motel ❑ Ofiher . <br /> dNumber of bedrooms- <br /> Number -_ Gaer <br /> rbage Grindw------------ Size----------- --------------------------- - <br /> ----- ----� <br /> Number of living units:---.f--._- <br /> -----Private <br /> Water Supply: Public System and nam_a---- --- <br /> Character of soil too depth of 3 feet: Sand❑ Silt❑ Clayl❑ ,Peat Sandy l - ya p' x <br /> Ho rdpan ❑} Adobe.❑ FII,Mate}ia f yes, tYP <br /> etc. must be. Iaced,on,�revirsedside.) <br /> (Plot plan, showing size of lot, location of System in relation fo'wells,'buildings, p . `i ` <br /> � . <br /> t---,. _. <br /> NEW INSTALLATION:, (No septic tank-or seepage pit permitted if public se, 1. available wit in 20d,feeY,) �f <br /> ! r :6, <br /> C TANK [�] Size------ Kt '`�--- --�Liquid(Deptly- -- -------------- <br /> SEPTPACKAGE TREATMENT [ l y !� I } <br /> Ca acit ��jj��,,,,,, '�`,�� c``C%j Material = No. Compar r'rief'fsC .`: �' . <br /> P y�; -E°----=TYpeiF--- -- - t <br /> !J _ Foundation._ _-P op. Line._ ) <br /> +� <br /> Distance to nearest: Well._- c,7-- ---- <br /> . e-- -------- -----__;Total Lengt �F -- ----- <br /> LEACHING LINE [ ] Noofines.-----a-------------- Length f each f lin !/, <br /> ! -------------------- <br /> D <br /> ' Box__- ". 1`'�pe Filter Material-0 a th Filter Material_--_._ _ <br /> :.. .. .. <br /> '----T f d D P _ �r 9 <br /> Distance to nearest:Well__ lf" S ---- <br /> Foundation_- ---------------Property e , <br /> -- <br /> _ Pro art Roc fk Filled Yes ❑ No ❑ <br /> SEEPAGE-$ITDe[ l �pth---- - ------- Diameter__. - " --Number--------------------------------- - _ .- -,. .; �. . <br /> Water Table Depth------------------ -- ---------------- <br /> Rock Size-------------------- '' ----- <br /> . . �._ -----.Prop. line <br /> Distance to in Well--------------- -Foundation____________________ <br /> REPAIR/i-DDITION (Prev. Sarin tion.Permlt#- ----------- ------ ------------- <br /> ------- <br /> -�-.Date'---- -----.------------------ ) <br /> F <br /> Septic Tank {Spec Requrreme'�s)----+-- ---- ---- -----------------.-- -= -----_-,����-��---- ---- ----- - ---- j--1--- -1---�-- <br /> ' -- - ------------------ ------------ _! }----------------- ---------------------- <br /> posal!Field (Specify Requirements]-.----.-- '`s=-- - , <br /> ----�_ ----------\--- - = -- --- -- ----- - --- ---------- <br /> Dis 11fX <br /> --------__`-------i-:------ --- --C 1 <br /> existrn and re ui ed ad�c ition on reverse side) _." "" <br /> e <br /> .(,Dra g q ` de) ' <br /> I hereby certify that I have prepare f 5s application and-that the work willl'be done in accordance with an Joaquin County <br /> Ordinances�State Laws, and Rules a'nd Regal tions of.the San Joaquin Local Mealth District Hom owner or licensed agents <br /> sighature certifies the following: <br /> �.. ` <br /> 'I certify," that in the per formance.of;fhe work''-for wFiich this permit'is issued,�l 1�a11 not employ anyr person in such manner as <br /> I to become,,subject total ma Com e ati lavrg to California." . <br /> 4. ------""_-_____ - <br /> 4 Owner <br /> Signe <br /> (` '..Title -------- - ---- -- -- !- ------ <br /> (If}other than owner) �a;� ✓ <br /> FOR.DEPARTMENT USE ONLY f <br /> r <br /> APPLICATION ACCEPTED BY__�.__--- 1 -��-----------•-------��.- ----------------` DATE. -------------- ------ <br /> �' --Z- _DATE------------- a <br /> ------------ <br /> ADDITIONAL COMMENTS_ i �- F <br /> ---------------------- ------'-------------------------- ---- <br /> DIVISION OF LAND NUM ."----------- <br /> _ �- <br /> ' - ---------- ------------ '=r ----- ------- --------=---------- - <br /> �` ------------- <br /> ---------------------------------- <br /> ----- - - <br /> --------------- - - - __ _ -= - <br /> ----- ----- -- <br /> ---------- <br /> ------------ - ` <br /> Z <br /> - - ----- =------Date. - --- - ""� <br /> i Final Inspection b --" <br /> r&5 21677 REV. 7/76 3m <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT /905 <br />