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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - ------------------------------------------------ Permit No- $-l.242 <br /> ---- ;7 <br /> (Complete in Triplicate) <br /> ------------------------------------1------- --------- I- - <br /> --------------------------------------------------------- This Permit Expires I Year From Date Issued Date Issued-. -5 <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 /> ----------------- -------- ---------- -------CENSUS TRACT--------------------------------- <br /> JOB ADDRESS/LOCATION.-..-* --- --- <br /> 7 ­ w <br /> - --- ------ <br /> Owner's Name--------/<1 ------- ---- ------------------------------ P h o rfe3- <br /> ------------*- ------------------------ ------ <br /> Address---------- --- city- —--------i Zip_4Aj!5-- <br /> # <br /> Contractor's' Name--.-- 7F— ------------------------------------ ----LicensY -------------------- Phone---------- -------------- ------- <br /> Installation-will serve: Residence Apartment House Ej Commercial E] Trailer Court El <br /> . 1 <br /> Motel-7.1 Other-.---------------------------------- --------- <br /> 1�--Lot'Size-- -------- -------------- <br /> Number`pf.livinq units:---- ______Number of b&'d rooms --Garbage Grinder- <br /> -- ------ f ---- ------ ---------Private <br /> Walter Supply: Public System and nar.ij ---------------------------I---------------------- <br /> Character of soil to a depth of 3 feet: Sand Silt E] Clay E] Peat E] Sandy Loom-1K C lay Loom Ej <br /> El <br /> iHardpan M Adobe r] 'Fill Material-- _-----If yes, type--------------------------------- <br /> (plot plan, showing size 1pf lot, locatio'n of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION.' I(No' septic tank or- seepage pit peirmitted'if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT I ' SEPTIC TANK -j I Size---6 -Ne, ------ ------------Liquid Depth- ------------------------ <br /> 7 �Capacity/ ---.-.Typeyo��- .C4-57-MaterlaI---------------- --- ----No., Co artm Ints--------- --------------------- <br /> CY <br /> Mistdince.to "hear,est: Well.- -------------------- ----Foundation-.=j Line--------------------------- <br /> i el Length- ---------------------------------------- <br /> LEACHING LINE' No. of Lines— -- - ---------------Length of each 16 Ao�� <br /> P-D' Box_1___ -Type Filter Material-.ONe.;�--bepth Filter Material.........A5 <br /> ---------- ----------- -------- -- <br /> e ------ ----------------- <br /> IDista" nce to nearest: W I ---------------------------Found&GA?o _________.Property Propeiity Line----- <br /> -- <br /> "..4. - <br /> SEE <br /> P (3- ]Depth�.- a-­ YDiametet---JY-17 ____Number---------- Roc�k Filled Yes No'E] <br /> ------------- <br /> ocl� Size_.-Table Dep ------------ <br /> --------------------- ---- ------------ R ize---------------------------- ------ ------------ <br /> ih <br /> Distance to' hecIrest. W41lA---- Prtp �ine---------------- <br /> - <br /> - ---- ---------------------------- <br /> __.Foundation-_-_-------- --- --------- <br /> REPAIR/ADDITION (Prey. Sanitation Permit -------------- ---- -------------�­,-- <br /> er Date...... <br /> ---------------------- -------------------------- --------- <br /> Septic Tank,jSpecify Requirements)—— --------------W,----------- -J ---------------------- <br /> Disposal Field (Specify Requirements):-------------------------- --------------------------------------I---------,------- ------ ------------- -------------------------------- <br /> --------- --- ------ ----------- ---- ------------------- ----------- --------------------------------- ---------- ------ <br /> - --------------- <br /> r te <br /> ------------ ------------- -- --- - -1------- --------- <br /> ------------ 111r. ---------- <br /> ----------- -------------------------------- -------------------------- -- -------------- <br /> ' fDraw existi6 '66d required.ddc1iti6r) ojnr <br /> 9 reverse side): <br /> V <br /> I hereby certify that I have Son Joaquin ve prepared this-application and that the work will, be done in locclo-rdanc-e-with Count <br /> Ordinances, State Laws, arid Rules and Regulations of the Spn Jodquen �otal�Health Siistrik'.-Horne owner or licensed agerif <br /> 4 <br /> signature certifies the following:.- bii <br /> "I certify that in the perforrnance cififfhework for'which thii'perffiit is issued,d-shall not employ- .-any,person 'in'tucti,rr,tanner <br /> ,j <br /> to become s6bilectipl/Wo mqn pm ensation laws of California. <br /> Signed ------------- ---- ------- ---- ------ <br /> 7 'j.. .... <br /> --------Owner <br /> ------------------------- ----- -------- --------- ---- <br /> If owner)r) <br /> BY------------------------------------ ------:-J -Title------ - ------ <br /> (I. 6the Aanli <br /> FOR DEPARYMkN!PSE 00�tY,,, <br /> P <br /> APPLICATION ACCEPTED' BY------ --- ---------- ----------------=----------DATE.-- - ------ <br /> DIVISION OF LAND NUMBER------- ............. . ---- -----------::--------------------------------------------- DATE---------------------- ------ --------- <br /> ADDITIONAL COMMENTS--------- <br /> ---------- --------- —-------- ------- - --------------------------------- <br /> --------------- ----------------- ---------------------------- ------------------------------------------------------------- ----------------------------------------------------------------------- ------ <br /> (N, <br /> --------------------------------- --------------------- -------- - --------:--------- --- --- - --------- -------------- P----------------------- ------------ ---------------------------------------------------------------------------- -------------------------- -- - ------------ --------------------------------------7------7-------------- ------------------------------- ------------- <br /> Final Inspection by:-------------------,.*----------------------------- - ------ - : ;�8 <br /> ----------------- <br /> nl!--- -----------------------:---Date.- S � <br /> F&S 21677 REV. 7176 3M! <br /> EH 13 24 SAN J UIN LOCAL HEALTH DISTRICT <br /> C45 <br />