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`~1ueu+mCuUSE, <br /> ` <br /> APPLICATION FOR SANITATION PERMIT <br /> Application is hereby mdde to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is mcCde in compliance with County 9rdpance No'. 549 and existing Rules and Regulations: <br /> -------------------- <br /> Contractor' <br /> . . <br /> Installation will serve: Residence 0Apo,mnentHooxef] Comm*nJa/ []Trailer �� \ <br /> \ ' ��'- -*� \ <br /> ^ <br /> Motel []Other --_---_'—_---- <br /> Numbprof (k,imJ units.-/-------- Number of bedrooms .'3........Garbage Grinder ---- Lot Size ---------------------- <br /> Water Supply: <br /> � '���------_-WoterSupp|y. Public System on6'nome -----------------------------------------------------------------------___--'_--.- ............Private [] <br /> , <br /> , O`umcte,of m»i| to u depth of feet. Son6][] Silt0_ Clay .0 . Peat[I <br /> / <br /> Hardpan Ado6e'E] Fill Material ------------ If yes,type ---------------------------- <br /> . <br /> (,k, FJon showing size of lot, location of system in relation *rvveU� buildings, etc. must be placed on reverse side.)) <br /> � ' . .. <br /> NEW , (Nu septic tank or seepage pit permitted if public oovm, iuavailable within 200 feet) <br /> � �� <br /> ^ <br /> PACKAGE TREATMENT [ ] SEPT|CTANK�� 8|za.u�.�+..+m-�J�*.-'-----' Liquid Depth Y-u-----__ p� <br /> � Copodty / --,__ A"��- ��oter|ol --.-' No. Compartments --`--.-- <br /> � <br /> Distance naoro��. VVe | ' �«�° Foundation �� ' Line �~� . . <br /> ^ , . ------_--_--_' --------' Prop. -_-- - _-' «�� <br /> � <br /> LEACHING LINE U� No. of Lines ��------.. Length of each |imv- �.�- ^-.----. Total Length JR��~--'_'--' � <br /> / 'D' Box ------------ Type Filter Material --------------------Depth RKe, Nkzmahpl -------_----------' 7�~ <br /> Distonce to nearest: Well ---------- Foundation '�m.----.-' Property Line. 47--------------------- <br /> SEEPAGE PIT <br /> -.-.__--SEEPAQEP|T Depth '���� --._ Diameter %A .---'- Number -��---� Rock Filled----------- — " v� -- No -- <br /> ' Water To6|o Depth ~ <br /> ..^��~� __-----'--'_--Rock Size .«J!-.-7. '--__'- <br /> Distance ^to nearest: Well ����'� ^---'---_--------Foundation .�/�"�.~_'-- Prop. Line .x��'__-_' <br /> / (Prev Sanitation Perm|t# -------------------------------------------- Date ---------------------------------- <br /> Septic Tank <br /> _'_-'--'_'--'JSepticTonk (Specify Requiremenfs) --------_.---.---.------_----_.--_--',-_-_-_,----_-----.. r~ <br /> . � <br /> Dispoou| Field (Specify Requirements) --'_,-----.--_--'_---_.------._--------___----'_._' <br /> .--.^�_---.------_-!.---_----'___'__'_'-----.---''__-'-------_----'-'--- <br /> .~� ~-=_�~ °�_~~_ ._~�~~ � = ~ -_ ' �^,+__ <br /> -- .1 = <br /> (Draw existing and required 866|tiononreverse side) <br /> | l hereby *e,Hf* that Y have prepared this application and that the work will be 6wme in ww«wmdmnwe with Son Joaquin <br /> > \ <br /> County Ordinances, State Laws, and Rules and Regulations ofthe San Joaquin Local Health District. Home owner orlicen- <br /> sed agents signature certifies the following: <br /> "I certify that /n the perfonmanx4i of the work for vvhywh this permit in issued, U nhm|| not employ any person in such manner <br /> as to <br /> 6 b[ k Yformla'" <br /> | S|gnod ..��� - - - -- Ownor <br /> . ^ <br /> By ----------------- -_—.----_'--'_-'_- JNo -------'---------------------.---- <br /> | (|fother than owner) A... <br /> . ~A <br /> FOR DEPARTMENT USE ONLY X <br /> | <br /> APPLICATION ACCEPTED <br /> 8Y`- ~ <br /> --=—� �-- '--'--'----'—'-'--- DATE �~—��-'. <br /> »'- <br /> -- <br /> '-- <br /> BU|U]|NG PERMIT ISSUED .--. -'' -- -------------------------------- <br /> _-- - '�--�DATE ' -- -'--- -ADD0ONAL COMMENTS -_--''-. � --_-�-_'---_-__ ---. __ '_'__--.---'_''_—.- <br /> ''-'---_—'_---_-�--�---_ � ._mm_ - ' . . ' '-.. y -------- <br /> ----------------------------------- <br /> '' <br /> .--.--- ------'---_'-----�-�------__--.------_'_--' <br /> ---_--_-'- ----_---_'____---_---'_ ------ <br /> Final <br /> F|n�l Inspection 6v --Dote -���...^�'- � _- <br /> -'�._--'-'---_----_--__ � -- <br /> SAN JOAQU|N LOCAL HEALTH DISTRICT <br /> ' . <br /> � E. H. 9 l'\68 Rev. 5M, <br /> ` . <br />