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f FOR OFFICE USE: FOR OFFICE USE: <br /> E APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate <br /> Permit No.-_ � -. <br /> ------------------------------------ <br /> Date Issued--;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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 7 <br /> JOB ADDRESS/LOCATION--.-__ lfv r/4_4 _,_ :_ ,_CENSUS_TRACT- -- ---------------- ----- <br /> .. --- - �--.:j.� <br /> Owner's Name-- ---- -- ---------------------- - - <br /> .` -----.Cit �A4®�-- - I--------------------- <br /> Addres�- ----�-......... �-� ------------ --- --�---- ----- -------- ----- - Y�-�- - ---------Zip--one---------� <br /> Contractor's Name--------dF----99-N_ .fl.C3 License #-/0 J 6f�---Phone-�r .3-------------------- <br /> t <br /> Installation 1will serve: Residence's Apartment House ❑ CommKcial ❑ Trailer Court ❑ <br /> Motel ❑ Other --------------------------- <br /> ------Garbage Grinder------- ----Lot Size-------- -- r ------------t----------------- ------ <br /> Number of diving units:------ -.-------Number of bedrooms <br /> Water Lpply: Public System and name------------------- ------------------------------------- Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loam ❑ <br /> I1 Hardpan X Adobe❑ Fill Material-- - ------.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,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth---_.__---------- ----_ <br /> Capacity---------------------Type - ----- --------------Material--------------------- ----No. Compartments ------- ---6^ <br /> Distance to nearest: Well-- --------------------------------------Foundation--------------------------Prop. Line-ttt--------- <br /> -------------- <br /> LEACHING ZINE [ l No. of Lines.-------------------------A_.Length of each line a Length --------------------------------------- <br /> l 'D' Box------------Type Filter Moterial------------------- Depth Filter Material------------------------------------ ----------------------- -- <br /> ' <br /> v Distance to nearest: Well------- Foundation----------------------------Property Line----------------------------------..t4 <br /> ------ <br /> SEEPAGE PIT [ ] Depth----------------Diameter-------------;------Number_._-------------_--___-------- Rock Filled Yes ❑ No ❑ ]r <br /> Water Table Depth N ------------------------ Rock Size <br /> 1 istarrce To nearest: Well--------------- R <br /> ----------- ------- - Foundation.-------------- ---------.Prop. Line------------- --- --------- <br /> REPAIR/, <br /> -------REPAIR/ADDIT <br /> ION Prev. Sanitation P ------------ <br /> [ 1� r r <br /> Dioral Field (,cif Requirements)---- ----------- <br /> --------------- <br /> Septic Tank'(S e yJs ' -------- ---t -----�----------- - ---- ---- -------� _ <br /> ---------------- <br /> p Specify Requirerhents]1--.- t �� ------ --------------------- --------- ---- <br /> _4 � �-Pz----------� - <br /> X - -- -- -------------------- <br /> - ----- ---- - ------� �t3 x <br /> j{ t -IX <br /> ------------"--s ----- ----------------------------------I-----------:- =------------------------"--l""--------------------------------------------------------------"----° ----. ------------------------ <br /> .� <br /> (Draw:existing ana ret�ui ed�a�cdition an reverse she <br /> I hereby' <br /> ereb'Uf that 1 have preparedthis a clic tion aii-c fK6`tthe work will be done 'in at corcrance with,San lJoaquin County <br /> Ordinances,' State Laws, and Rules land Reguli tlbns of the San Joaquin-Co2bl'Mealth District'Homeiowner or licensed agents <br /> i v i I '� . <br /> signature certifies the following:4� � � � � }� J ;�I - � <br /> 1 <br /> "I certify fhat in the performanceCof the work for which tli.is p�rrnit is issued, I shall not employ any person iri such manner as <br /> to become 'subject to kr n s11, Compensation laws of''C`60o nia.f - "• i " <br /> I / Owner <br /> Signed.-�'"�- -------- --- ------ ----;- -------- --------f ---= <br /> f ,.._-'.... .Title-- <br /> BY {= -------- <br /> ----------- <br /> at <br /> a ---- -- -- - <br /> ._. ..> ;. <br /> ty (If other than .owner] <br /> l OR bEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY # j = - --------- ---- ------- ------------------- -----DATE S7=f f. ` -------- --------- <br /> w...-- .-_� r / <br /> I I <br /> DIVISION OF LAND NUMBER -------------- -- _ r DATE L .. <br /> 1 - _. <br /> ADDITIONAL COMMENTS ------------------------ ----- ------------------- ---------------- --------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------- --------------------------------------------------------- ---------------- - <br /> Final Inspection by:_- Date.- - --� .- - <br /> EH 13 24 SAN JOAQUIN CAL HEALTH DISTRICT F& 7,Rev. 7/76 3M <br />