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FOR OFFICE USE: FOR OFFICE USE: <br /> I IL-,(ro APPLICATION FOR SANITATION PERMIT Permit <br /> ..................................................... (Complete in Trip licaiell <br /> -------------------------- t. Date Issuedt-1�n7_01' <br /> This It Expires 1 Your From Date Issued <br /> h s Perm <br /> .. ... ..... <br /> A'- 01[_ 03 _0�� <br /> I,P---7 A9- 11 the work herein described. <br /> Ap f;lUt, to gets <br /> .p is tion is hereby ode an Joaquin Local Health District for a permit to construct and i <br /> TMs application is TeN. <br /> ncerilth ounty rclinance No.549 and existing Rules and ReguIation2:.,,.,_,..4&40"v 9t- L_ E _TOACT...... -------- ..........C NSUS,ii <br /> --- -1 1 4.JAB A;1DRESE/L0CA <br /> Phone-------------------------­--- <br /> ------------ <br /> ...... ..... <br /> OWner s Ndme..--- ... ........ <br /> If[ i �?Is I i City.......... ............... . .............. ... <br /> Address..... ......... ... ... <br /> ........... <br /> 4ntractor"s'INam ....... ... ------- - ... .... .License----------- ........ <br /> Apartment House.[] "IC'orn"merrial 0' <br /> c Tller.Court [I <br /> Installation w' ill serve: Residence <br /> 4-. Motel [] Otl�er---t- <br /> T ....................... <br /> 1 4 . - ��lotlsliii ------42c--.•.•••••----------------- <br /> NUfnber of ilvin� units:_ .........Number of bedrooms.-.._3_._Garbdge Grinder—i.. <br /> ---------- -- <br /> Water Supply: Public: System and name.-..' ............. --- ------ -----­------­-----_­------- <br /> ----------- <br /> cl: <br /> IndEl S-11to ClayC] Peat Z Sandy Loam Ej Clay Loam <br /> Character of soil to depth of 3 feet: so <br /> III i . - q .1-- <br /> (P¢lot <br /> _tD­ Adobe Ll 'Pill Material..... .._...if.....if yes,type.......... <br /> Ii.lot plan, showing size of lot, location of system in relation to;wells, buildings,etc. must be place( <br /> :1 on reverse sisystem[W INS TION: - '(No'septic tank or"seepade pit i3ermitted 11fpublic sewer is avoilable within 200 feet, <br /> I <br /> ....... ...................... ... -Depth.... <br /> _PKCKAGE-TREATMENT --i SEPTIC TANK ....... <br /> en ------------- <br /> ........NIT. <br /> !�;,;_:Type ........ ter ------I <br /> Caplilciti..:.... 4,4! <br /> i7op. Llne.__........ <br /> s. Fou1dot1on,q_'.77.-..—_:-'­ P <br /> _j Distanceto nearest-WelL, <br /> .......... <br /> No. of Lines, h ci� each line.... �Qtal <br /> LEACHING LINE -----------w...... jendt...., ,each. . ...... <br /> V Box..;-..._.:..T °e Filter Mdtirlal.!--------------i-----Depth Filter Maternal..__._-----. ....._....___......_ <br /> Distance to nearest:Well_'.____.'..._._.... ..._.Foundation____....._...._'._ Noperty-Line..j............... ---------------- <br /> SEEPAGE PIT I Depth................Diamiter......... ...... Number---!......i.... ------I- ffi- 'ARodkFiIIJ 'Yes [I No <br /> ................. ....... <br /> 01 water Table Depth._...... ...... ............. <br /> oundation_..!............j&! <br /> ­61stiance,to nearest: Will.......... !.Prpp. Line.,..i�............. <br /> t ! . . 'I / I <br /> &AWYAD6(TION (Prey Sanitation Psrmit-#--- ......`_-1: --- ------------ .71 <br /> ...._:_x.:.- - i. - - W.. <br /> ....... - --- ----- <br /> Septic Tank�Spelcify Requirements)—... ........... .................. <br /> -------------- <br /> DI sdI Field {Specify Requirements); <br /> ...... .... <br /> ...... . ... ... ......- ........ . <br /> ------------------- ------ --- -------- --------- ------- ------ .......... ....... ....... ................... ...... ....................... .................. <br /> II t prow existing and required addition*o n.reverse side) ",' <br /> that the work will be done In accordance with Son.Joaquin County <br /> I hirel3y.,ceirlify that I have prepared this application and 1 - <br /> 6rdIndjtces,! State Laws; and Rules and Regulations of the San Joaquin Local Health District,.,Home owner alicensed agents <br /> lig6aiure certifies the 1`9110�Anq: <br /> I I clnypscm In iucli manner as <br /> 'in the performance of the work for which this permit is issued, I shall not employ <br /> �'l c fy that <br /> 'in <br /> become 4ju t to Workman's Compensation.laws of California. <br /> Signed-------'-----------..: ..! --------_--- 'Owner 151 <br /> JAI <br /> 7--- ......2-------- ---------- ------ <br /> ------------ -------------- <br /> FOR DEPARTMENT USE ONLY <br /> . ............... <br /> - <br /> �PPLICAT10 ACCEPTED ..... . ..i.... .i............;------......... . _DATE. - - <br /> ----IVISION OF LAND NUMBER - ---- DATE --- --- <br /> ------------ ........... ........ <br /> ADD COMMEN[TS.............__-----------------------•------ <br /> .... .................... .........................------- <br /> A --------- ..... --------------_---------------- .......................t..................... <br /> - --- ------------ --------­------- ------------- ------- <br /> ...................................L....._77,--------------- .......... ................ <br /> ......... ... ........................­­�....... <br /> ........... <br /> ----- ----------- ------ <br /> ------- ------ <br /> ......................... ...... <br /> .. ..........n..Date.. <br /> I Inspee:tion-by!.,.��.,c.. ..... ... ....... ...... F&S 21677 REV.7/76 3M <br /> 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />