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FOR OFFICE USE: FOR OFFICE USE: I <br /> ld , APPLICATION FOR SANITATION PERMIT <br /> ----'------- '-------------- ---------- ---� r.. Permit No. -'-------- <br /> � - S�z <br /> (Complete::in Triplicate) <br /> w's f tr ''. <br /> -------------------- Issued <br /> Date -------------------- <br /> --------------------- ----------------------- <br /> -.-----------------------_-------.------____---- This Permit Expires I Year From Date Issued <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 /> -- - - <br /> . . .. .�..._..,-.. -R -, - _ <br /> i <br /> JOB ADDRESS/LOCATION-_�------------- - -- -- ------_------4------------- " CENSUS TRACT r <br /> 0hon <br /> Owner's Name . - - -- ---- '�------' -- .... ------- ----.=------- ---- ------ -- - e _ <br /> A <br /> Address. pe�G, ._ - " City --- Zip <br /> License " <br /> Contractor's Name-..=I .`_ C ----------- ------ ----- -6 #._bz�l.S 3 Phone' . <br /> se <br /> Motel-- --r Other - ---------- <br /> ----------------- <br /> ------------- <br /> -_ --_ !- s a <br /> Installation will serve: Residence ❑i Apartment House ❑ Commercial ❑ .Trailer Court.❑ V , <br /> ] r 5 <br /> Number of living units:__ ..- Number bedrooms.____-_Garbo a Grinder._-_ Lot Size_.-..i f' d__.--- .--'.- <br /> g t <br /> ` ) £ Private [ <br /> Water Supply: Public System and name,.-.-------- _- -- ------------ - -------: �❑ <br /> Character of soil to a depth of 3 feet: , Sand ❑ Silt.Q Clay❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ _ { <br /> Hardpan Ado6e Fill Material--.---.- If-yes,type----------_---------------- <br /> . -- i <br /> i ` t <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings;.etc, must be placed on reverse side.) <br /> NEW INSTALLATION: `(No?septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> . r , <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] = Size_ -------------------------------------i _ ----Liquid Depth - ----..: <br /> i i .-"I1 ` 4 4 <br /> t . ._,.Mate•vial-- ------- ------------------No. Com Compartments --------=-------------- <br /> Ca acctP F <br /> ( Distance-to niearest: Well_e...........: ._,_._ <br /> Foundation. Prop. Line = Q <br /> LEACHING LINE [ ] No. o f Lines=-------------------- -:Len_gth of-each line-----.----- ------------ --.Total--=--.Total Length.:--------------------------------------6 <br /> 'D' B' ----- Type Filter Material:- . ___Depth Filter Material.__;__ _. ----------------------------------------------------- <br /> ,Distance to nearest: Well------------------------ ----Foundation-. ------------------ rope y Line---------------------------- _ __ <br /> E PIT [ ] Depth--------------- Diameter ---.--..Number ----. -------_ Rock Filled .Yes ❑ No Ef <br /> SEEPAGE -Rock Size---------------f. <br /> --- - -----=--------- ---------------- <br /> Distance to nearest: Well--------------------------------------"7 <br /> Water Ta e'De t --=------=---- � ------------------------- <br /> ] Foundation ' . Prop. Line 1 ► <br /> . t . <br /> ---SeREPAIR/ADDITION (Prev1Sanitation Permit#-----=------..`_.----------''------'--------------Date :--------------- ------- - - ------ ---- <br /> Se ic <br /> ptic Tank (Specify Req lirement� s)....---_=--- --" --- - -- ----------------------------- <br /> Dis' osal Field (Specify Rbqui <br /> - G - - <br /> P p/ y q P - ------------------- ---------- <br /> - <br /> t <br /> . . .........--- --- ---- -------- ------------ ---- <br /> ...................._ - - .- Y , <br /> __ -. .. .. .._. <br /> {Draw exls in and require a diti an r erse side} <br /> I hereby certify that I have prepared this application-and that the.'work will b`e done in accordance with 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 performance of the work fora which this permit is issued, I shall not einpldy any person in such manner as <br /> to becom bbie t 4o Wo on's ompensation..laws of California." t <br /> Signed i ' �•-- --=--- = Owner <br /> ------- ---------------T <br /> Title <br /> other than `o er[ i <br /> .tom- -----'---FOR-DEPARTMENT• .SE:O Y'- .. <br /> I <br /> APPLICATION ACCEPTEDBY--------------------------------- ---------------- ------ <br /> f <br /> - '_-`--DATE , ��-��=�C? ' ------- - <br /> DIVISION OF LANA NUMBER = = ---- DATE.' : : ------ ---------------- <br /> --------- 1 <br /> ADDITIONALCOMMENTS----- -------------------------=------------------------------------------------------------. ------------------------ ----------------------------------- <br /> --------------- ------------------------------------- -------------- ----------- -------`----------------- ----------------------------------------------------- ------------------ ----------------------- <br /> ------- <br /> ---------------------- <br /> -----=-------------------------------------------------------- -- ------------------------------------------=---------- <br /> } - -- --------------------- - ------ -------- ------------- <br /> --. <br /> Final Inspection b ----'-----'---------------------'------ --'---------- -'.„.'�,a..----- -- - `°.Date.�:�.��`�' ---- - ------------------ <br /> EH <br /> ------------- - � <br /> P Y�---��.'..,.r �f�1�j <br /> EH 13 24 SAN JOAQUIN LOCAL HEALT ISTRICT r�L�677 REV. 7/76 3M ' <br /> 1/ J <br />