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FOR OFFICE USE: FOR OFFICE USE: <br /> .f APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> --------------------------------------- <br /> " (Complete in Triplicate) � <br /> --------------------------------------.----------------- <br /> Date Issued._!.�_T _ <br /> ________________ ------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to ther,San JoaquinLocal Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordindnce No. 549 and existing Rules and Regulations: �- <br /> JOB ADDRESS/LOC l N.,-- � 2`�.---- _ _- �3 I' M1 ` ----- CENSUS TRACT _ <br /> { <br /> Owner's Ndme.I--- - -- --Phone_ 1 � •�1 <br /> s} � !� <br /> S-- .40 ----s --- . ----- City-" �`�:r 1 -_--Zip--- - ' , --- <br /> Addres -- �' J�P <br /> ► o { k r.. <br /> � � _ <br /> ntractor's Name -- --� _ - �` ,---- -�-------- -•-License # � Phone _ --------- <br /> Co4 --- <br /> Instal lation�will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ 1 . <br /> .,.. ,; ... : [] Other .` -- ---- _ ----------------------- <br /> Motelf ; <br /> i...... <br /> Number of Iivin units:_ -- - ____Number of bedrooms ___Garbage Grinder Lot Size �: _._ .. <br /> � l <br /> 9 / <br /> Water Supply: P.ubhc System and'name ---------- ----- - -- -------------------------- ------ ------- ----Private f <br /> ---- -- - <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay 0 Peat ❑ Sandy,Loom ❑ Clay Loam <br /> t. .. <br /> � Hard'pari Adobe ❑ Fill Material_.. _�.__If yes, type_ <br /> l �_ <br /> - t i <br /> (Plot plan, showing size of lot, location of:system-in relation to,wells, buildings'�etcrmust-be-placed on reve_se side,} <br /> NEW INSTALLATION: ;(Noiseptic tank oroseepage pit" permitted if p__ublic_je\&eris available within 200"feetJ f, <br /> l ?° -;-q l ` -- fki '•------':._ _ `q cJ Dep <br /> "No"'Com artme <br /> pm_ � P PACKAGE TREATMENT [ ]p SEy'T1CTANK pSize _ Li uints__- 6J: -Ca acct ��6.0-�_ �. ----- 4tstral__ - - <br /> p . °� a r <br /> oundation = = __..:_.Prop. Line----- <br /> EACHING LINE No. of Lines-,�_____.___ Len o�2�__Depth <br /> h lime__.,F1 � r L. } <br /> ,Distance.to nearest:.Weli___Q .__: _._ ------------ <br /> - <br /> t .. - <br /> Total Length. = o�- <br /> L .- _._. g <br /> D' Box., __.___.__T e_F,ilter Material_ Filter Material---�8�------.----;------.------- - , <br /> vt � ._. I � 4 <br /> '; -- <br /> �Distance,to nearest: Well_,__E._Q_1: ____.___-Foun anon____ ___ _________________P operty Line _____ _ <br /> y y _ --r � <br /> SEEPAGE PIT Depth-�:'_ - Diameter- __ Number"._:___ :_______ + Rock Filled i Yes,K No <br /> l L'- ------------ - -Rock Size 1__ _�C —3E.��/ Y 4 s <br /> s Water Table De th---'_ -- �_ _.._ ; <br /> p - <br /> I -- --------- <br />. �* Distanceao nearest: Well.__�. C��_____________'__:Foundation:_:__.�®_P.__.Prop;�Line--_-,-�-� y <br /> REPAIR/ADDITION (Prev." Sanitation Permit#-=............. ----------- : -----------------Date----------:--------------- -- - ----1 ' <br /> Septic Tank (Specify Requirements)------------------ - =--------- =-----„--_ ..........................................., -------- --------- <br /> Disposal Field.(Specify Requirements): - . ._. ----------------------------------------------- ------------- --------------------------- ---- <br /> � ' { <br /> -----`-- <br /> ----} _... .- (Draw existing and required addi 3 - _: ii <br /> l --- -- - <br /> tion on reverse side) <br /> I hereby certify that.l have prepared this application and that.the-:work rWill Qb clone in accordance with Sam-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 fallowing: ` ? <br /> "I certify that in the performance of'the work for which this permit is issued I shall not employ ariy person in such"mariner as <br /> t to become subject to-Viorkman's -Com sation la <br /> California.”Californmia." <br /> Signed_ <br /> ----- ----"---`---- - ..__--- <br /> BY -------=----- - - __Title <br /> .e_ ------sr: <br /> --- _ ------ ------------ <br /> = � . ... <br /> I If other than owner)1 <br /> ' `FOR`DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY- ;---- <br /> - ----DATE.'. �'-7-/------------------=------- <br /> -------------OF LAND NUMBER- - --:-- -:- --DATE-'-_-----------=--- ------ ------------------- <br /> DIVISIONF ADDITIONAL COMMENTS ----------- ------------------`--------------------------- --------------------- <br /> ---- ---------------"-------- --------------- - - <br /> ------=---------=----------------------------- ----------- - <br /> -----',-"------------- -----------` ------------ ------- ---------_------------------------------------- ------------ ------------------- <br /> t Via" �� ��' <br /> ----- <br /> --------------------------- ------------------ ----- ---- _ ----- <br /> Final Inspection b - - <br /> Date---- -= ✓ ' � <br /> EH 13 24 SAN JOAQU LOCAL HEALTH DISTRICT F&S 21677 REV, 7176 3M <br />