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FOR OFFICE USE: <br /> FOR OFFICE <br /> - ----------------------------- APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> ------------------------------- ------------------------ <br /> -------------- ------------------------- --------------- Date Issuecl_//.-7,,P_ <br /> This Permit Expires I Year From Date issued <br /> Application is hereby made to the San Joaquin Local Health,"Di'strict for-6,13\ CO-7-2_5,0--7 <br /> ermif-to construct and install ihe��workk herein described <br /> This.application is made iri--compt-ionce-with-Count-y-Ordi�-nance-No-549-and�exiiting-Rules !scribed. <br /> -and-Regulations. <br /> JOB ADDRESS��_=xTION...Sj <br /> - - ------- -- -------- <br /> --------4ENSUS TRACT--------------------- <br /> O�ner's N <br /> -- ------ ------- ------- ----- ----- -------- - ------------ --------- <br /> ame ---------------------------- Phone <br /> -T <br /> Address ---------------- ------- <br /> ­- ---------- ----------- --- --- --City---- ------- :-----------Zi <br /> ------ ------ - <br /> P--------------------- <br /> Contractor's Name----. <br /> # P <br /> ---------License --5!,2--------------------- honeA <br /> ----------------- <br /> Installation-will serve: Ceside'nce' ei Apartment House.f-] <br /> Commercial E]_-'Trailer Court E] <br /> Motel E] - Other------------ <br /> ------------ <br /> Number.of living units:------I----- ---Muniber.-of�bedroo' m,_:___?_._Garbage Grinder- --------Lot�­Size._­ <br /> ---------- ......... <br /> c Sys m. e---- ----------- -- --------- <br /> Water Supl�ly: Publi' 'tem and qa <br /> --------------- ----------- -------------- -------- <br /> ------------Privai'e A- <br /> Character of soil to a depth of 3 feet./ S6nd Silt[] Clay Peat <br /> Sandy Loam Clay Lo <br /> am <br /> Hardpan Ej 'A'dob I;p - <br /> e� Fill Material------------if ye.s, t�y.pe----------7------------t�-------- <br /> (Plot plan, showing size of lot, locatiq�n of system in relation to.wells, building s, 6to. must be fa�ed on reverse side.) <br /> rp <br /> NEW INSTALLATION: 'jNo"�ep7t1E*`f1a'n'k"-or sepage pit' permitted if public se-wer is avail&Ne`w'i_thin 200 feet,) <br /> PACKAGE TREATMENT -SEPTIC TANK jyj Size.4 <br /> Liquid De'pth.__'e------------�D--- <br /> Capacit _J��_P_!q --.,--,Type-- : ' "�'L' . r _/ . - , -.11 <br /> y .....!�_� --No?Compa'tments_:-------?-—----------------------- <br /> ------------- --- ---------- ------ - <br /> N�ell..............�'Q <br /> Distonce'Jo.near st: <br /> rop. Line------II_ <br /> --------------- -----Fdundation._! -L_ <br /> ines_�__ <br /> LEACHING LINE No. of Ll :: 1 4 o i <br /> -------Length of-each ------ S <br /> --- T�ta I L ----------- <br /> D Box__�_J------T�ype Filter Material_­_-.Sf�------Depth Pilter <br /> Distance to nearest: Weil ------ Foundation� <br /> :-- ---- ------ Property Line-,----- ---------- ------- - ----- <br /> SEEPAGE PIT 'Depth....:��r <br /> ---Qiameter-; <br /> ----- ----.Number-----------1*__� <br /> ------------ Z� F"I es Ej <br /> --------- Roc �i led Y J <br /> Wat�r f. able'bepth---------- <br /> c -------------- <br /> Distan�&'to nearest. Well� 41�OhE7��� <br /> ------------- ------Fo0nda ---- -----Prop. Line--------------------- <br /> t ------ <br /> REPAIR/ADDITICIN (Prev; Sanitation Pe' rmi <br /> -------------------- <br /> ----- ---- ------Date--: <br /> Se�tic Tank (Specify Requirements)--------- -- ------ <br /> ------- -------------------- - - -77 <br /> ------------------------- ------- --------- <br /> ------------ ------- <br /> Disposal Field ---------------- <br /> pecify Requirements)-------------- - -------------- ---- <br /> - ----------------------- -------------- -------------------- ------------------ - -------- <br /> ---------------------------------- --------------- -------- ---------- <br /> -------- ------ ----------------------------------------------- ---------- -- -------------- ----- <br /> -------------------------------------------------- ----------------- <br /> ------------- ---------------------------------- --------------- ---------- ------ <br /> ------------- -- <br /> ...... ............. <br /> (Dr w existing and required addition on rever% ' "a -) - " I— <br /> se si e <br /> I hereby certify that I -have prepared this'application and that:the �work <br /> -will, be done -in -accordance with' Son Joaquin Coun <br /> Ordinances, State Laws� and Rules d Regulations of' the San Joaquin Local Health District i Home owner or licensed agents <br /> an <br /> signature certifies the follow_ j�g:` <br /> "I Certify that in the pei-'Fbirnan�e of'the work for which this Oerm-'it"Is.: issued, -1 shall not iiii I -a uch ner'aO? <br /> pay ny person i6 S m an <br /> to becomesubject to Workman's -Compensation laws of California." <br /> Signed------------------------- ---------------- <br /> Owner <br /> -------------------------- ---------- <br /> By.- "Title- <br /> ---—------ ------------ <br /> .0f. oW ----------------- ---------------- <br /> other fha'n n r <br /> F 0 R. D E.P"A'RT MM EC N IT U S E ONLY <br /> 'J�� JNL y <br /> `=ATE <br /> APPLICATION AC PTED' BY ----DATE. <br /> CE <br /> ------ --- -- ------ <br /> 0 � :::���-- --------------------------- <br /> DIVISION F LAND NUMBER----- ---- ---- <br /> ------ --- ---------------- DATE_,�--- --------------------- <br /> ADblTIONAL COMMENTS---,--------- <br /> ------------ ----------- ------------------------------------------- <br /> 4 ---�­-------- --------- --- -------------------------------- <br /> ---------------------- ------­------------ -------------: ---------------- ------ <br /> ------------------------------- ------------------ ------------- � .I <br /> ---------------------------------------- ----------- ---------------- ------------ ------ <br /> ---------------------------L-------------------------- ------- - <br /> --- ------ ------------------------------ -------------------------- <br /> ----------------------------------------------------------- <br /> --------------------------------------- <br /> ------- -- - -- ---- ----- ---- ------ -- - ------ ----- ­-------------- <br /> Final Inspection by:--.,-- -------- --- ---f_. _� <br /> ­-------- -- -------- --------------- --- <br /> EH 13 24 <br /> SAN JOAQeUIN CAL HEALTH DISTRICT F&S 21677 REV. 706 3M <br />