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3 <br /> FOR OFFICE USE., FOR OFFICE USE: <br /> rAPPLICATION FOR SANITATION PERMIT r <br /> (Camplete in Triplicate) Permit No.-- <br /> _r <br /> te Issued.—-?-:��-� <br /> t <br /> _- <br /> ----------------------------------------- This Permit Expires 1 Year From Date Issued �„ ! <br /> ' t <br /> r Application is hereby made to the San Joaquin Local Health District for#a permit to construct and install the work herein describe,d. <br /> i This application is made in compliance with County Ordinance No. 549 and existing Rules and <br /> Regulations <br /> --.CENSUS TRA <br /> CT------------------------ ----- <br /> JOB ADDRESS/LOCATION.-- ---- --� ----/o----- <br /> f ---------- -- ----------- --- -- <br /> Owner's Name..---- --------------- ` ---- -- ---- g - `� = <br /> L�GP.-Phone Z i �7 <br /> ----------- <br /> Address.---- ------- ��d ---- -- ---- --------- ------- :-- ----- <br /> ® � �. <br /> cense i L' <br /> Phone -_/4.� C/ <br /> Contractors Name----- ----,-{- -------, ---•--------- --- ---------------- <br /> # ���..�.3 <br /> - - - <br /> Installation--willserve: Residence [:1 Apartment House.E] Commercial ❑ Trailer Court : <br /> -...n ..Motel'-E] Other-...'--------, -- a <br /> Number.of living urri#s:_ _-- -----'Number.of,bedrooms�_-/.�_-Garbage Grinder--------.---Lot':Size-----_-__----------------=-= -----_= - ---- <br /> i <br /> 1 <br /> Water Supply: Public and name---- -- -.- = -- ' .-. ..:.. -------------- -. <br /> :. :. ------------- -----=---------Private <br /> - System a _ = --------------- . ------------'- - � t <br /> Character of soil to a depth of 3 feet: ' SanI Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> H&rdpari❑ Adob6 Fill Material......;------If yes, type-------------------- � s � � <br /> f (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'`lseptic tank -or seepage -pit permitted if public sewer is available within 200 feet,) ] K d <br /> y - _ _ .. .__---- <br /> a Liquid, th.:--- �Q <br /> Ca acit --- ------- q P <br /> Material_.:--------- -- k <br /> PACKAGE TREATMENT [ ] -SEPTIC TANK. -[:T„ 'e-=--. ' ize ------------------------ <br /> .- Il--------=----- -- .-_Foundation- 'No. Compartments- ------------------ ----- <br /> AN <br /> Distance.to nearest:.We - ---==------ ----- ----------------- Pro Line-------- ------------------ <br /> Len ----Total Length T''.--------------------- ------------- <br /> LEACHING LINE.' [ ] No. of Lines,___,.,-.:-._.___--..---.,- -: .Length of each line---- --------------------- � �{ , <br /> Box- <br /> TypeFilter Materia ------ Foundation-------- '------Depth Filter Material = --------------------------- ------- -- ------- <br /> tis ance to nearest. Well ------------------- ---Property Line----------------f------------- <br /> =-- <br /> SEEPAGE PIT [ ] ; Depth----i-----------Diameter--------------------Number------------------------------'- a Rack Filled es ❑ o ❑ <br /> Water Table,Depth--------------------- - = Rock Size <br /> ----- -- ----- <br /> -- <br /> Distance to nearest: Well--------- <br /> G f: - ----------- ------ £ ---------------Prop. Line--------' ---------------- <br /> REPAIR/ADDITION (Prev.-Sanitation Permit#: 1 --- --1'---- - -��-- �5� � <br /> -- --- ------.Date -- -------_ - --- ) <br /> Septic Tank (Specify Requirements)--------------- i e---------------� --=------ - ------=------- --_---- --------------------- <br /> --# --------- ------- <br /> Disposal Field (Specify Requirements)---- ---;?%'- - -. ¢ --- - _ �.. ti _ <br /> -------------- <br /> -- <br /> ---- <br /> ------------w - -------- ---------------------- <br /> ---------------- <br /> ----------- <br /> -- <br /> o - fi S <br /> . --p'---- ---__-__-.-- <br /> --- --------------------- -..---_.__------_--___-------_--.-______---:-____-:--____---.-______---.--___-------_.______-------------._:_._ �ti--^— <br /> (Draw existing and required addition:on reverse side) --r <br /> I hereby certify that I have .prepared Phis application and that the work will be done in accordance with San Joaquin e County <br /> Ordinances, State Laws, and Rules and Regulations of the San JoaquinLocal Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> kk "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 beco u jet to Wo ma Compensation laws of. California:' <br /> Owner ] ti <br /> Signed r� `-- ------ ---- - l <br /> r - ---- <br /> B - ; <br /> - ---------=--Title - <br /> (If other t n' wner) <br /> F j R D ARTM T M E ONLY 4 } <br /> ------ ----- -- -- -----'-------DATE.-- --�---.L- -----.-- - <br /> APPLICATION ACCEPTED BY--- ----------- ---------- ( _ <br /> DIVISION OF LAND NUMBER.. ----= -. ------ -.- ---- <br /> -----=---------- - - ":.DATE --- <br /> ADDITIONAL COMMENTS ------------------- - -------- -=------------- ---------=------------------------------ ------------------ <br /> --=-----------= = =---------------- -------------------- ---- -------------------------I---------- -------------- <br /> --------------------------------- --------------- ---I-------------- - --- <br /> k ` - _,---•---- ------------------------•__-----------_._------------------------------------------------------------_ --_---------------'}_- -----•-- <br /> _- --- �Y r(/ <br /> Fincil Inspection•b -- - --------------' -- - Date <br /> -- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fa_S_�1677 REV, 7/76 3M <br />