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FOR OFFICE USE: FOR OFFICE USE: <br /> 2 o � 'APPLICATION FOR SANITATION PERMIT <br /> -------------------------------- - ----------- �.� <br /> {Complete in Triplicate} <br /> .'Permit No.------ �---/•gam <br /> -- ----- <br /> ------------- <br /> ------------------------ <br /> This Permit Expires 1 Year From Date Issued Date Issued_"2.--;?-4F_-7P <br /> Application is hereby made to the San�Joaquin Local Health`District'for a permit to construct and install t4lwork herein described. <br /> This application is made in compliance with County Ordinance No. 5 9 and existing Rules and Re lotions: <br /> _¢ � : If _ _ <br /> JOB ADDRESS/LOCATIONF : <br /> -- - <br /> = NUS A <br /> Owner's Name: � �� - Phone_ <br /> :,Address_ , <br /> y- <br /> �. _ _ Zip--- <br /> ------ -- ------------- <br /> C � Z -� <br /> Contractor's Name 7/ ---------- - �'License #_ f Phone a <br /> :."t. <br /> t <br /> InsFallation will serve: { Residences Apartment House ❑ Commercial[][) Trailer Court ❑ # <br /> ,. Motel ❑ - Other- ------- - <br /> Ncimber of living units:__ _ - _Number of bedrooms---�,2 <br /> - Garbag€e Grinder-_ -."Lot;Size-.-"-_ G:___ �__ <br /> Wdter.Supply: Public System pnd nam <br /> G_% -•-.- -------------- <br /> ---------- __ _ Private <br /> ` Character of soil'.-to a depth of 3 feet, 'Sand ❑ Silt❑ :Clay ❑ Peat ❑ Sandy Loam Clay Loam❑ <br /> 1 Material_.._.- if es, e.__.__ _--- <br /> Hardpan []�` Adobe r Fill ; <br /> '(:Plat plan, shoving size of lot, locationiof syatem'in relation to wells; buildings, etc. must be placed on reverse side.} —� <br /> fAEW INSTALLATIONc {No_ septic` tank or seepage pit permiitedf public sewer is available within 200 feet,M <br /> PACKAGE TREATMENT - [ ] SEPTIC TANK—[-] Size_______ a <br /> ] I i --- ---- ----- 'Liquid Depth._ ��--------------- -- <br /> Capacity-J-- --_. Material ----- --=- ----No. Compartments--------- <br /> a ------------ <br /> _.=. .;Distance.to.nearest: <br /> , ;.. Well r -,o- ..---.-a-tion- <br /> ro ----------------------- <br /> p..Line <br /> fihof each,line.of Lines-- ------------------=_ LegLEACHING LINE No. - -'---- .Total Leng thi <br /> ___.__ <br /> D <br /> Box__."..__.___Type Filter Mpterial7_f_._�_('Depth Filter Material--.________________.__" '___ <br /> . .. ------ <br /> `'_ *? i <br /> 'Distance to nearest: Well_'------ ________-Found Foundation -_ __-__-_-_ ~___Property Line___________.__________ <br /> k. ... r, y: w• ------ <br /> SEEPAGE PIT j ] Depth------------ --Diameter-_------ -:----Number--- ----.- ----- --------- ---- # <br /> i.. Rock Filled Yes [] No ❑ <br /> : <br /> p ._. # Rock Size--- <br /> ------------------ -------- -----. <br /> .. � <br /> Water Tgble.De th-------- - ----•------------ ', _ <br /> _---1Foundation- --- -.Prop.1Line------------- <br /> REPAIR/ADDITION Prev.Sanitation Per&it•#------------ <br /> ------------------------------------- <br /> Distance to nearest: Well_`._.'___ _________________ ___ -7 <br /> Found <br /> __.Date:: <br /> Septic Tank {Specify,Requirements[---___ t <br /> 1 = ----- <br /> Disposal Field[Specify.Requirements]_. ..__ 6 _. _ *~,�, <br /> t � -- <br /> i <br /> --------------- <br /> - -------------- <br /> - -- <br /> -=---------------------------------- ------------=------------------------------------------ <br /> F <br /> (Draw existing and•required addition on reverse side) <br /> hereby certify-that'l have prepared'this application and that.'the-work will be done in accordance with San Joaquin County <br /> Ord inances;�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 cern that.in th�e1"" , + . - � . � 7 <br /> certify perfo-rmance_ofrtl a_work-fog-_which4his'pe-rmit-is-issued;I-shall-not-employ any person in such manner as <br /> to 'becom sect to Wor an's .Compensation laws .of California." s <br /> Signed_ -- :� -( 1 { <br /> BY------- --- -------------- <br /> - <br /> .. ... <br /> " Ownj <br /> . .. - -- --- -------------- ------ ------ ----Title�- <br /> (If other thari ner) <br /> 1' FORONLY"- <br /> USE y <br /> ... <br /> APPLICATION ACCEPTED BY------ _ _ =' �' <br /> ----DATE.------ <br /> DIVISION OF LAND NUMBER ------------------- <br /> ------------ --------------------- <br /> VIS <br /> ------------------ = -DATE ---------------------------- <br /> t ; <br /> ADDITIONAL COMMENTS­ <p-r ­/ '______ _______ <br /> ---------------------------------- ------ <br /> ------------ -------------------------------- ------------ ----- <br /> ------------------------------------------------ <br /> ' s ------------ -------------- <br /> ------------ -------------------------- ------- <br /> Final <br /> -----Final Inspection - - — ------ <br /> - -, <br /> - ----- f- <br /> ---- <br /> EH 13 24 67" �J �J Q F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M <br />