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FOROFFICEUSE: <br /> : FOR OFFICE-LASE: <br /> C- �. „ "` �� APPLICATION FOR SANITATION PERMIT ` <br /> -- ,.�: <br /> ter--r 7�_ <br /> �� --- --- ------- (Complete in Triplicate) Permit No..______-__ <br /> ----------------- ------- - �(-- -- This Permit Expires 1 Year From Date Issued Date Issued--�-3-�� <br /> r. <br /> Application is hereby made totheSon Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application-is made in complionce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB <br /> FADDRESS/LOCATION <br /> �*li -_ -- ---- - ------ L y` -� _ - -------�----f-'---CENSUS TRACT----- -------------- <br /> _ <br /> Owner's Name.------- ` <br /> Address- :------------------------------------- <br /> ------------. Phone <br /> �_-- <br /> -. ------C <br /> .., .e. ..�. it ' ------ <br /> r / ZAP:, - <br /> i <br /> Contractor's Namef}Gfti�rry�Fi�1/�l CJ-- yyXfeee R7, � , g <br /> t s License #_-3 <br /> a�-------Phone-_C�-f).J-j'!/� f <br /> Installation will. serve; Residence kr Apartment House [J Commercial y <br /> ❑ Trailer Court ❑ <br /> 7 - <br /> +-4,-Motel ❑ Other._: <br /> = _v... <br /> Number.of-living units:_- '�:______Number,of-bedrooms-__._ <br /> ► Garbage Grinder-.---- Lac Size. 4�_------"Y <br /> Water Supply, Public System an�d.narrie_---�. __-- ::---- <br /> �. N # , _. --- --------------------------------------------Private <br /> Character of soll to a depth of 3.feet: ' Sand . <br /> �� . ❑. r5llt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe; '' Fill Material es, <br /> ' p Y tYPe--- - <br /> -------------------- <br /> (Plot plan, showing size of lot, Potation of system in relation to wells, buildings, etc, must be placed on reverse side.) P <br /> NEW INSTALLATION: No septic tank-or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT , <br /> [ ] S i�PTIC TANK' t ------•%':r!i o-Q a- it t <br /> Capacity---/G----_----- 'T S e ` <br /> --Liquid Depth.-rf --- <br /> Distance to nearest. VII JP --- ------- Mate_rial—:---.---------- No.'Compartments----_-2----------------------- �Q <br /> i 44 O-------- Line-. <br /> LEACHING LINE. ['). No. of Lines- _.--_----- -'-----:Length of each line---------------------- <br /> -------=-----Total Length.------- <br /> -------- <br /> + - { r Material'_----_:_-----------Depth Filter Material__________ ____ <br /> D' Box��-______-_TYPe Filter 3 <br /> a 4 Distan e to nearest: Well <br /> 1t. --- =--- '.----Foundation -• ' ----- Property Line----- -- f <br /> F <br /> SEEPAGE PIT ,f�j Depth-. ; _� -D'iameterZa�X ` '�Number--- __-- <br /> I lI <br /> _ ; ---------- 1 Y <br /> Water Table Deptli-------------------------- <br /> --------------------------------- <br /> ,�.. . _ <br /> -. Roc <br /> s �i <br /> ._ . .;� --.Rock 15ize� F.-� -- <br /> es <br /> Distance to ne&est:'Well- /_P.4_ r' oun <br /> �{ <br /> dation ..Prop. Line <br /> 'REPAIR/ADDITION (Prev., Sanitation, <br /> ,e y yPermit#-_-_-_-_-_-_-_ _ <br /> - ate_____- <br /> Septic.Tank (SpecifyRequirements)---._- 4 - = ° <br /> 't <br /> _ __ _ __ ____ f� <br /> .F <br /> ___,_ <br /> Disposal Field(Specify Requirements)'uiremIie <br /> �nts); - -- - <br /> --- -- <br /> -- -- - --- -- - ---- <br /> --- ---- <br /> ------- - ---- ------ <br /> .. -_ <br /> r' <br /> - ---- -- -_--' -- ---- ---- <br /> _'- <br /> ------ - --------- ------ --- ----------------------- --- <br /> t (Draw existing and'regiiired'addifion on reverse side) ` <br /> I-hereby certify that I have prepared this application and that the work will b }' <br /> e done accordance with San Joaquin Coun ° <br /> in <br /> Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agent <br /> signature certifies the following:" <br /> h _tel, <br /> "I eertify that irf the"performance of'ahe work which this ermit is issued 'I shalt riot employ any y person in such manner a� <br /> to bg�� nn i ' ' ' R y <br /> Signe _ #ensationi laws..of .California+ ; <br /> - -- Owner <br /> BY *.... . <br /> n <br /> r ,--- -_- ---- - <br /> . ---- --- - T� # <br /> (If other•.than,owner) " - -- -_ -- <br /> ' 'tie d r €. t r t <br /> :,. FO�R �DEPRT�MtN` 'USE'ONLY;. .. <br /> APPLICATION-ACCEP,TED BY-_ <br /> -- -- DATE. <br /> DIVISION OF LAND NUMBER.. �( ` --- <br /> �� :------------ ----'------ <br /> '..._ <br /> ADDITIONAL COMMENTS ... b - .__ t ----------- ------ ----------- <br /> •.►...o- 9, - _._.-__�_____._ ------------------------------------------------------------- _ ___ <br /> ------- I'. - __ ___________________________________ <br /> __ ___________ - ---------------------- <br /> i <br /> -------------------------- J ------ <br /> - -- - - - -----_-- <br /> ----- <br /> r1l <br /> ----------------- <br /> - --Final.-inspection <br /> b _ i - <br /> ;1-------- ---------- <br /> --=- ---------------------- <br /> Date---- _-_ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7176 3M <br />