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FOR OFFICE USE: FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT 7,�- <br /> ------------- ---------------------- °(Complete in Triplicate) Permit No.------------------ <br /> --- <br /> --------------------------------------------- ------------------------------- i Date <br /> ---------------------_---------- ____._.__----__ __ This Permit Expires 1 Year From Date Issued <br /> �U <br /> Application-is hereby-made-to-•the-San Joaquin-Local-Health-Distri t-for-a-permit-te construct cn`d`insfiall`the work'herein d`escri6ed. <br /> This application is made in coni pl:iance with-County-Ordinance Nom 4�9,and-ezisting Rules and Regulations: } <br /> ._� ---- ----------- ---- <br /> '� EN S TRACT.---- . <br /> JOB ADDRESS/LOACAION.___- _ ---------.- -- <br /> Owner's Name_----- - - ------ /P`< one--------------------------------- <br /> 111C <br /> ------- - ----------------- <br /> - G <br /> Address --- ------------ ------ <br /> y - -------------------------- <br /> Gontractor's Name_ .� ,---- -. _--/J�rJ`�icense #_� --P1�ane_ <br /> Installation will serve: r Residence Apartment House.0 Commercial ❑ -Trailer SMP fi <br /> it Motel ❑ Other = = ------ k <br /> 6 <br /> Number.of living units:------ ------Number of b`drooms...�__Garbage Grinder'_ _Lot Size------ _� ° .____-.--.-- -- <br /> fter Supply: Public System and name_ ----------------------------7­_­----- <br /> Wa ____ <br /> .Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Si'lt,❑ :Clay ❑ ` Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> ' Hardpans Adobe.�] : Fill Material_____;__..__If yes, type---------- ------------------ - <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: (NJseptic tank'or seepage 'pit permitted if public sewer is available within 200 feet,{ ; <br /> PACKAGE TREATMENT [ ] )'SEPTIC TANK" Size_ __ _-. <br /> � f � e"-- -� - - IU1att�al�- --- - 1C�---- No. Compar mentD�pt^�-�--------------_-��Q <br /> Capacity/�e YP •� <br /> if Distance to near.est:.Well--.-•.1 �! _------- -------_--:•.---=.Foundat:ion-_.-�,t ---- -----Pro Line-- -----------------. '.�.( <br /> LEACHING LINE' No. of Lines'__-i length afch line Total Length..'-­ __,a _ <br /> r � - <br /> D' Brox --Type Filter 'Material�,E` ----_Depth Filter Material_ '._ _ f--y- - ----- - -- ------ <br /> r <br /> Distanc6to nearest: Well--� - ______Fo`ivndchon Property Line! <br /> ��� r i i+ Rack Filled< Yes, No <br /> T ice' De th Diameter 9.:-. Numblt'e . _ ❑ - <br /> P. ` <br /> SEEPAGE PI Water Table DeI51h :- -- ------- - - '- ---A--- -'Rock=Size __ --- <br /> Distance to nearest; WeILG ____-;_ ;__ �_Fohi"ndafio__ -,� Prop;'Line ---- - <br /> E'at ` j.r— ` r <br /> REPAIR/ADDITION (Prev:Sanitation Permit-#---- -------------'--- --i-- -== Date-- '--- <br /> t. ' 4V � -- - 4t`k <br /> Septic Tank (Specify Requirements) _- -- --- . ----- --- ----------------- ---- --•-- - <br /> : mnts)t-------- - --=Disposal Field {Specify Requiree � <br /> = --- --- --------- ---- <br /> ------- --- - <br /> i ; <br /> Ex f -------------------- ------- ----- <br /> ----- ------------------------------- -------4---------- a-I---------------------- - , <br /> [Draw existing cl eequired addition on reverse side) I r <br /> I hereby certify that.) have prepared,thls application and that-the iwork will be done in accordance with San Joaquin County, <br /> Ordinances,' State Laws; and Rules and Itegulallons of the' San Joaquin Local Health District, Home owner or licensed agents. <br /> signature certifies the Following: : i <br /> "I certify that in the performance of.the'work for which-this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation.. laws..of California." <br /> SiI w RENCE' S DTIC ;gE'1iuR�SERVIGE <br /> - --- <br /> GL{l S <br /> - - -- . ._ nar ib - <br /> r; 5<<..: <br /> y- a <br /> ....:._ <br /> T - <br /> itle - 20 , 95215`. i'A <br /> BY- - ---------- -- - --- --------- .�--- -- Yi.lof.,.. ��7 <br /> (If other th owner) ( " <br /> FORD PARTME�T USE ONLY <br /> APPLICATION ACCEPTED BY "`" - DATE.-------/-© :- --7g-------•-----�`--- <br /> - /N --- ----- ------ ---- -- <br /> DIVISION OF LAND NUMBER y °` ;: --------------- ------------ DATE..._ : <br /> ADDITIONAL COMMENTS------------ `.----- �. ------ <br /> -------------------------------------------------------------------------------------- <br /> i S _ .. i - ______________________________________--------------------_-------------- <br /> ---------------------------._._-______.___-.---____-_-___._--___._.____- ___.____._-+.____ ._.-____.___-.-_____-__.______ <br /> I <br /> _.__________________________________________________ _______ _.________-__.--- ___._:_.-----______.__-___----- �c ____ ----- <br /> - <br /> __ ____ ____ _______ <br /> _ -� - .�.�w-x .- : -----_ ---_ ----- - <br /> Fina] inspection-by ection�6 - �"r��'"a- : Date '_ �" "'�� <br /> �_ <br /> EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M <br />