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l FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT t <br /> ---------------------------- ---------------- -- <br /> (Complete.in Triplicate). Permit No.�$��.�.----�„;- <br /> Date Issued_-9,7-f--7`dr <br /> -------------------------------- ------- This Permit Expires 1 Year From Dale.Issued+ <br /> -�1 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ADDRESS/LOCATION. .. s <br /> IA <br /> JOB ^ � , <br /> E - -` " v°`G.` - CENSUS TRACT........ <br /> Owner's Name. ,. .. .:---- ----�-----------=--- ----- - Phone_ 7------ - <br /> LIQ <br /> ii t <br /> l.�`' <br /> Ad00, <br /> dress. yJ'rQ City - Zip <br /> . .,.. <br /> Contractor's Name-- .- _______________________ License #._ .7 /------Phone_ --------------------- <br /> Installation-will serve: Residence ❑ Aparlmenf Nouse ❑ Commerci I f��'Trailer Court ❑ <br /> Motel'❑ "O}•herA- _ .. <br /> Number of living units:------------------Number-of_bedroorns:_ __Garbage-Gender - - Lot Size -�e�e.-x.a___._r__:._____._ _______ <br /> Wafer'Supply:-Public`System and name T :' -----------.- - - --- -------- Privr <br /> ' c� <br /> - - -- _ - <br /> Character of.soil to a-depth of,3 fee.t...,_Sand ❑ SiIt..OClay ❑ _,Peat,❑_ 5dyoam,.0 Clay Loam <br /> Hardpan ❑ '. Adobe ❑, Fill Material------------If yes,.type <br /> (Plot pian, showing size of lot, location ofsystem.'m relation to wells, buildings, etc. must be placed on_reverse side.) l <br /> NEW INSTALLATION: [No septic tank or seepag rit: ermrtted U public:sesruer is available,with '200 feet�)� a <br /> PACKAGE TREATMENT [ ]' 'SEPTIC TANK[']' Size. _ �'S _.___ hiq iu d`bi'—7 <br /> ..._—TCapa.cityS- --- -T.Ype -- -----------------:Material--------- ---------------No:rComp rt7nents 44------------------ <br /> Prop <br /> - -------- <br /> `Distance to nearest: Well_:_ __.___. _____'________ Foundation. E,r f_i.Prop. Line________ ____________ <br /> '- - <br /> LEACHING �No. of Lines____________ ___ __________Length of,each lina,1_ ---"' _�_'__.__ otal.Length:____.____________-__-.________________f <br /> .:. - <br /> :D' Box _._ !--Type Filter"Materid __ __ __ Depth Filter M t al_ _� --------------------------------------- <br /> 4­ <br /> Distcince;to;nearest: WeIL'_______ Foundation_ Proper Line <br /> [ ; p ---... r ) ❑ <br /> SEEPAGE PIT ` e, tht . •__ --biometer.?_-- _Number___: - ' Rock Filled Ye�s� .'-�6[I- <br /> ' i � Wa er Table:Dept h ° ---- - --- -Rock Size <br /> ✓ '' "-^ F <br /> ---- <br /> D stance to nearest: Well.:_ __,_. <br /> c� ` ` ''A <br /> EPAIR/AD.pITION (Prey. S nitatiorr Permit#__r.__ :-----------------------------------------`�fi ` _.Datedatian3_- __ L' ____-_ <br /> F <br /> Septic Tank [Specify Requirements) -_ C- ;- ----- <br /> _________ _______-______._______._______ _ ------ <br /> -------------------------- <br /> Disposal Field [Specify Requirements)-,----[%�-. -- _ -- /- --_-__-- � .- __-- ------_ _ -- - <br /> - ----- °' ---------------------- <br /> ------------- - --- - ----------------- - <br /> __ - ------- ------------- 1 •--- <br /> t i {Draw existing and required addition-0Wreverse side] �__t .�.�r . _ <br /> hereby certify that I have prepared this 'application and that,the work will be-done tin- accordance with San Joaquin County ' <br /> Ordinances,' State Laws, and Rules and Regula ion\s. of-.the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the fallowing: ' r .. s <br /> k ti <br /> "I certify that in the performance of,the work for which this permit'is'issued, •1 shallinot employ any person in such manner as <br /> to become subject to Workman's Compensation..laws of 'California." <br /> Sivied--------.--- - --------------- ------------------ -- <br /> ig <br /> BY ------•- Title <br /> ` <br /> ---= L <br /> (If t <br /> a <br /> other than owner) <br /> OR•DEPARTMENT'USE ONLY. <br /> t <br /> APPLICATION ACCEPTED BY_-_ _-- "= :_: DATE--- <br /> ------------------ <br /> DIVISION OF LAND NUMBER!;--------------------------= --- = - --------------------------- -----'------------------- ...........DATE- ------------------------ <br /> _____ __ _ _ _ -_--____ -------------------------------- <br /> ____________ -�. _.__-_.__-___ <br /> ADDITIONAL COMMENTS-----`-------------= ----------- <br /> -- --- --------------- ---------- ---------- -i.- - ------ ---- ------------------------------------------------------------ } ------- = ------------------------------------------- <br /> ---- -------------------------- <br /> ------------------------ ---------- <br /> ---F-------------------------- ------ ---- -------------------------- -----------•-•------------ --------------------------- ---- <br /> Final Inspection-by: = ��` = =`.° - =Date 1 <br /> IHEALTHIjFes 21677 REV. 7/76 3MEH 13 24SAN JOAQUIN LOCAL <br />