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T <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------'--------------------------- ---- <br /> _ (Comp4ete in Triplicate) <br /> Permit <br /> -------------------------------------- --- ---- -------- lL-_.- 7 <br /> ._._._7 <br /> -..-_____.___---------------------------------------- -- This Permit Expires 1 Year From Date Issued Date Issued_.�-. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constru and"irstaI1-the ork-herein-described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC fON " " ' �-r" ' ------ ---- �--:•- 'CENSUS TRACT '- 1 <br /> * � <br /> Owner's Name.- ''E#'I' --- -----' - z; --- -Phone -- ---- ------------- <br /> ' - City ---- - Zip------------------------------ <br /> Address <br /> �r . , -i .. <br /> Contractor's Name ----`-- ---- = =---------- License #_ �h5- Phane-- _-_-"� -�------- <br /> =' -•-' <br /> J p< ,Trailer[Court,❑ � <br /> Installation will serve: Residence❑ Apartment House Q Commercial . <br /> .r Motel. ❑�-:Other -------------------- <br /> g. <br /> ------------------ = '_'-__ _I' <br /> R e & ---------Lo#.Size.S�' -------------- <br /> Number of living units:---------'._ - Number,of,bedrooms Garbage Gander..__ <br /> Water Supply: Public System and:name ' : �° - �`._----- -------------- - ---- ----Private f . <br /> F ` _ w t 1 - __._ --- <br /> Character of soil to a depth of 3 feet: ' Sand [Silt ❑ Clay ❑ . Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adob6 Z E-Fill Material ____If yes, type--_. ---- ------------- <br /> (Plot <br /> --- -(Plot plan, showing size of lot, location of system in elation to.wells, buildings, etc, must be placed on reverse side.) Cr/ <br /> I NEW INSTALLATION:- (No!septic tan _&r seepage pit permitted if public sewer i"s available within 200 feet,)' <br /> PACKAGE TREATMENT [ ] SEPTIC;TANK "' Size-_=_7 _f-_ -----------3_-----------Liquid Depth..__________--_ <br /> Ca acit 1 e ` �Material_-----------------------�- - --Noir Com Compartments _ <br /> t P Y ='- YPP .� <br /> op P <br /> 21 Distance to nearest Well'._.-- --- --`-- --------=--------Foundation - ---------------Prop. Line-:-----------------------;o <br /> LEACHING NE No. of LinesA 2. �,__-Len.g'th of each line.__'________.,- _ <br /> .__..___ ._,,_,Total Length._ __ 3_ <br /> LI _________ <br /> D' Box <br /> ............. <br /> Filter MFilfer Maerial aterial- 1_ Q� Depth t ,_____ 4, ------------------------------------------------ <br /> �. x, �" w r <br /> Distance to nearest: Well_i•---__'--------_ - ____- <br /> __._ Foundation___ --------------------------Property Line-------------- .---------i-' <br /> SEEPAGE PIT [ ] r Depth---_-------------Diameter_._________.-__-._N'umber___=- ____ ______- Rock.Filled Yes ❑ No <br /> Water Table Depth ".r` : ------------'----- -------- --------.Rock Size------- ' --------- ------ ------ i <br /> f i = � � E <br /> Distance,to nearest: Well.--'----"-----'- "-- - -- --- -� _ Foundation--------------------------Prop.'Line---------_------------------- <br /> REPAIR/ADDITION <br /> -----------.- <br /> t <br /> REPAIR/ADDITION (Prev,!Sanitation Permit#----_---------------- <br /> , -- - Date---------------------------_'._-___ <br /> Se tic Tank (SpecifyRe uirenients) = - <br /> ----=------- -------------=----'---------- ------____.____}::---�_-.-_---_-_-`---')-..------------------'-.- <br /> - ---- <br /> - <br /> Disposal Field (Specify.Requirements)------- -------------------------------- <br /> - - <br /> _~ --------------------------------- o- ------------------------------ <br /> r - - - [ <br /> -------- -- <br /> --------------------- ---- ---- ° ------ ---- - - --� -------=-- ----------------------------------- ----------------- --- -- - ----------------- -------------- <br /> i (Draw existing and required addition on reverse side) ( s £ <br /> I hereby certify that I have prepared this application rand That the work will be done in accordance wiih San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in -the peiformance-of the work for which this permit issi sued, 1 shall not employ any person in such manner as <br /> to become sub' to. Workm Compensation laws of California." . <br /> Signed--'--- O.rRr <br /> ----------------------------- - itle---- <br /> ---- <br /> gY (If oth4 than owner( <br /> FOR DEPARTMM U LY i <br /> APPLICATION ACCEPTED BY------------------------------------------------ --------------- -DATfV'/x'!77 = -- - <br /> DIVISION <br /> - <br /> DIVISION OF LAND NUMBER --------- - - - . ........ .. <br /> --- ---- DATE_--------------- ------------------------------ ' <br /> . _.. ... <br /> ADDITIONAL COMMENTS------------- - R----------------------------- <br /> ---'-------------' ---- ----------- - <br /> : - <br /> d_- - ' - -----------------_______________-- <br /> ----------------------------------------------- ------------ <br /> ______ _____________________________________________________ <br /> ________________________'____4________.____�__�_____________________�_____ <br /> ---_._______-___.__ <br /> ___-._ <br /> 1 - ='Final Inspection by ------- --- ---- 6--------- ------- -------------------- --------------- --------Date ------- --------------- <br /> EH <br /> 13 24 SAN JOAQUIN LOCAL'HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />