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........... <br /> �R OFFICE USE: a FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT • <br /> (Complete in Triplicate) f Permit No----------------------- <br /> -------------------------------- Date issued - --/ <br /> `} <br /> This Permit Expires 1 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 a location is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATlO 7¢ �a z�--`. �f--_-'-�/_------- ----------- ---- -- CENSUS TRACT <br /> o - - --------------- --------- t <br /> ' Ph ne <br /> 6y- za <br /> Owners Name------------- <br /> Address------,- <br /> --------- <br /> - � '=---'-- ------ <br /> 8 - ---- <br /> Address----- -= -------------d " ..5 ----- ---- -- y Zi <br /> �r --- --C�t p- <br /> i - � . � . <br /> S --------------License . __. }--Phone__TiC�- -+ <br /> Contractor's Name-------- ----- -- ' <br /> Installation.will serve: Residence . Apartment House ❑ Commercial E] Trailer Court El <br /> .Motel ❑ 3 er_Garbage G----'-- �--'----'--- . <br /> ., <br /> ----------- -------- <br /> Number of living units:__-- ____ ___Number of bedrooms___ rinder-_#___.-"__Lot Size___l0__.__-_._ I I <br /> P t <br /> Water Supply: Public System.and name _ " ----------- <br /> Sandy <br /> z - - q <br /> Pr <br /> e <br /> .'� ��_=--- Clay Loam <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ ] Peat ❑ Sandy Loam ❑ Y ❑ <br /> . y tyP <br /> 6 <br /> Hardpan Adobe ❑ Fill Material____ if es, e ------------ -- --- ------ --- <br /> (Plot plan, showing size of lot, location of system in relation to welh�buildings, etc. must be placed on reverse side.) <br /> ' i.. <br /> NEW INSTALLATION:' ](No septic tank or seepage pit permitted if public sewer is available within 200 feet,] h <br /> i- ---size = _ - -----------------Liquid Dept -------- --------- <br /> PACKAGE TREATMENT­j ]""• SEPTIC TANK [.] � ,� i , <br /> Ca acit s I �`Type.r: i __,=`_ Mat€�r-ial%_•rr_-- ---- ---No' Compartments:_' <br /> p Y -- 1 <br /> Dista nce`to,nearest:.Well,.: - ---------------_ --:�►--Foundation. <br /> .__ .__:. Prop_ Line_._.__ <br /> No. of Lines-----=-----= --- ` Len�#t�`of.each line._-. - - ---�----------- Total.Length..' � ti_]` <br /> LEACHING LINE. 1 ] Yp � <br /> ---- -------Depth Filter Material----'---- L --- <br /> ' ... _ ----------- <br /> e-.! <br /> „ . <br /> ,D' Bog--------- T e Filter Material... ti • ; �. <br /> 1 1 to ;N�r,P`operty Line ._- <br /> Distance to nearest: Well_ ------------- ___ Foundation. - -- -# R k Filled Y ❑ <br /> s _ <br /> F t _ Diameter _:__._ _--Nurrlber: <br /> ----------------------- <br /> SEEPAGE i led es No❑ <br /> PIT ] ] ' Depth_ -- _ ,n? L s <br /> 1 r Water Table De #h._ ------------------------------Rock Size ----- � �-7 �� 3 <br /> ! Distdnce to nearest: Well ---- Foundation - "Prop VLine, ----------------------- - <br /> ' I ' Permit,# "= = -------sate;4 r -. _ _------ ----------] 3 1 <br /> 1, <br /> REPAIR/ADDITION (Prev.(PreySanitation Pe A ` ----------- <br /> --------- <br /> --- j%4---------------------- <br /> Septic <br /> T -------- ' <br /> Septic Tank (Specify Requirements)----- .}---- ------ i= - y_- -- - <br /> •,� -�-:< -1— --------------- <br /> Disposal Field (Specify Requirements]:_____-,� ,�- �Q - l Ri <br /> = <br /> ----- ----- -- -- _ . . y <br /> ,p <br /> 11 ----- ------------ ; � <br /> , °{Draw existing and required add]tion.on reve'r'se side} <br /> 1 fin accordance with Joaquin County <br /> I hereby certify that I have prepared this application and-that the work will be done,+ <br /> Ordinances; State Laws, and Rules and Regyj tions ofwthe__San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the Followings } <br /> 1 <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become?subject to Workman's-Compensation laws of California.” <br /> ' --- � --'- <br /> - ----------- -Owner <br /> Signed_:__ ---- - -Title- . <br /> � ----- -r------- ---- '--- --'------- ' <br /> ---- ----------=- ----------------- ---- --- <br /> t <br /> (If other than owner) <br /> k F R DEP RTMENT USE ONLY <br /> s l: d <br /> APPLICATION ACCEPTED. BY ------- --_-------- - -------------- -------------------- <br /> DATE - /-" --3-------.--- - --- ---- <br /> DIVISION OF LAND NUMBER-------------------------------------------- ---------- ---:- DATE ' <br /> ADDITIONAL COMMENTS_ - ' <br /> 1 _ <br /> --------------"--__-__----_ ._._.____._ _____ _ _ __------------------------------ <br /> _._.__. -- __-". <br /> - __"_______ ________ <br /> --------------------------------- <br /> _„__________ ___ _.. _._______ <br /> �I <br /> ate -- ---- <br /> Final Inspection-by...-- --------=------'- -'--------' - '-----=° � ---. <br /> ---F&�S <br /> 21677 REV. 7/7b 3M <br /> EH 13 24 r SAN Jl AQUIN LOCAL HEALTH DISTRICT <br /> r � <br />