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FOR OFFICE USE: FOR OFFICE USE: <br /> 4 <br /> APPLICATION FOR SANITATIONPERMIT � _ <br /> ..............:...... <br /> ------­----------------- - <br /> ......................... . . J <br /> (Complete in Triplicate} Permit No.._. . <br /> Issued....:/.�-_ <br /> This Permit Expires 1 Year From Date Issued Date � <br /> application is hereby made to the San Joaquin Local Health District for a permit to construct and instafl the work herein described. <br /> chis application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---.. _ _. .._ inti} C .............CENSUS TRACT........................ <br /> ------ ---%--- -- ---- - <br /> Owner's Name ,�> �2_iS�.�. 1 --------- Phone. <br /> . S - <br /> Address.. _ .7.>7 <br /> .� ( v -------------------- -- - - -----Cit L_../��d .Zi <br /> rontractor's Name -�A-f-,0`C .l-------9-- -------------------- -- --License #�_Sl- :�rq,3 --.Phone------ ------------ ---------- - <br /> 1nstallation will ser e: Resid 8ce ❑ Apartment House.❑ Commercial Trailer Court ❑ <br /> A AIN <br /> _4Motel n <br /> _ �� <br /> . 'qumber of Iivin units:------------ ---N ber of bedrooms------------(�bage ender------------Lot Size--------------------- ---.-.-------------._.-----.--_----- <br /> kti , <br /> _JVater Supply: Public System and 4aine------- --------- -------- -------------------- -- --------------------------- ------ - - --- -------------Private <br /> Character of soi to A depth of 3 feet Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy loam ❑ Clay Loam ❑ <br /> Hardpan Q] Adobe Fill Material------------If yes, type--------------------------- <br /> (Plot <br /> __ ...........(Piot plan, sheing ize of lot, loc ton of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> 1=W lNSTALLA 10 ({No septi' <br /> pt tank e�-sae�auge pit�m+##ed- ublic sewer is available within 200 feet,) <br /> _ TTII <br /> ?ACICAGE TREA ME T TA K Size - --- -----------Liqui eP -------------------- - ---- <br />{ <br /> Capacity_1-1 Type Mater alri% --No. Compartments------- -- <br />'l ______________________f. <br /> o I <br /> ItA <br /> � - --I - p• r --- <br /> Distance to nearest: Well..___._/-.-4.__ _ _ ___ _. Foundation_____________ _ _ _ ___ _ Pro Line_ . __ ._-.____.___ <br /> LEACHING LINE No. of L'ne ---------------Length of each Iii e....------------------------- <br /> Total Length.---.-----�e-----------------_-- <br /> ,D. Bo0j = e Filter Material------------------- Dept' <br /> Filter Material------------------------------- -- ---------------------------- <br /> 1P � <br />( �f Distarg (ode r st: Well____ _ �c_____Foun anon.. ' <br /> ---------.Property line-- - ----------------------- -- <br /> SEEPAGE PIT k <br /> [ ] Water�Ta --. eter___________________Number__: _____________ ___- - Rock Filled Yes No <br /> ble De th----------- ------------- ------ ; Rom z _ <br /> ------ <br /> Distance to near st: Well.-------- ----- -------- _f -_.FourrTgti n e----- - --- -----------Prop. Line.-------------------_ <br /> rEPAIR/ADDIT tBN ( rev. Sanitation Perm t#___________________._ ______ _._ _.Date..eptic Tank (Sfpecify quirements)------- --- ---- --- ------------------- ------------------ --- I----- ------------------------------------------------------------- ------------------- <br /> Disposal Field (Specify` <br /> - ` <br /> - - r.�.� - <br /> - - -------- ----=-----------------------� 0 <br /> (Draw existin ankt wired add ion on reverse side <br /> r � g q ) <br /> FJhereby certify hat I have prepared this application and t at the wor uit�County <br /> Jrdinances, Stc to Laws, and Regulations of the San Joaquin Local Health District. Home owner orifi ensed agents <br /> Af <br /> signature certifi s the Ilowing: <br /> 'I certify th th performance of the work for which this permit i issued, I shall not employ any person in such man& as <br /> o becom sub ct oCa nsation laws of California.' <br /> Signed------ =- .. <br /> 3Y----------------------------- --------------------------------- --- ".Title <br /> ------------------------------------------------------------------ <br /> (If other than ow er) <br /> FOR DEPA •M1E V E O Y <br /> R-PPLICATION A XE PTED BY-------- - ---------- --------------- <br /> - - �------DATE.---....."�.c5"��-------------- - - <br /> DlV1SlON OF LAND NUMBER.. ........... . --- ----- - -- ---- ---- -----------DATE------------------- <br /> ENTS ------------------------- ----------------------------------- ----------- ---------------------------------------------------- --------------------------------------- <br /> i <br />{ ALC M <br /> -- --- - .: <br /> a --------------- -- ------------------------------------------------------------------------•-------------- ------------- '` ------- ------------------------ <br /> F Jnal <br /> -------- ------------- <br /> FJnal Inspection by - ------------- ------- <br /> __H 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />