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FOR OFFICE USE: <br /> FOR OFFICE USE: � <br /> APPLICATION FOR SANITATION PERMIT 77 ,7 <br /> ----------------------- � t:w+� , --C '_ Permit No. <br /> -------- ---------------------- (Complete in Triplicate),-1 , <br /> �+' '':" Date Issued"-�- .`r---��- <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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regula-tions- <br /> '2W <br /> .3 NSUS TRACT----------------------- -------- <br /> JOB ADDRESS/LOC ----- <br /> ' - --- - <br /> + Pho <br /> -.- - ne - <br /> Owner's Name._--_ <br /> fyea :.. ...._Cit _ ----- <br /> --- Zip------ , -- -------- <br /> Address-- ------- - ---=------ � ---- _ t <br /> -�.� �_�- � License # _ -----Phone--'��----- :----- ----- <br /> Contractor's Name-. r ,- - -� -_ - <br /> - - ---• - - --_- - --- _ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court, ❑ <br /> • �.-. --r---•- _� Motel ElOther-'--- - ��r <br /> ' f`-. ." -----=---- ------------------ Y <br /> I _ -- Size--- - -- {`S <br /> Number of living units:. _ /` 1 <br /> Number of ber�rooms.- Garbd a Grinder-.-"- 1at private <br /> Water Supply: Public System and risme- ---- f + <br /> p i ❑ ❑ Y ❑ -..1f yes, Y y m ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt CIO <br /> Peat ( Sand Loam C!a Loa <br /> i Hardpan Adobe Fill Material—— <br /> � � <br /> (Plot plan, showing size of lot, location of system in relatiowi to w911s, buildings, etc.must be placed on reverse side.) <br /> .- <br /> NEW INSTALLATION: (No septic tank &-Aeepacfe pit.pe m—iited if public sewer is available within 2a0 feet,) , <br /> • --Liquid Depth.: -- <br /> PACKAGE TREATMENT [ } !,SEPTIC TANK [ ]r 1Ze . - ------------------------------------ <br /> Ca aclt Type,' = Materia ------=----- <br /> s.- <br /> -_No. Compartment ---"4� <br /> . r � <br /> Distance�to nearest: Well----------------=- <br /> _ r-_Foundation -- -- ---,__-Rrop. Line-------------------- ---- <br />` r ---------------------------------- <br /> -TotalLEACHING LINE [ ] No. of Lines." - : ----- :-- .,Length of ea,lh line -. --,- ---.---- <br /> Length-- <br /> Box------------Type Filter Material ----- Depth.,Fiiter Material ::------------- <br /> ------------------------------ <br /> -'D'I D-IStpnCe #O..ne - '� °r Line <br /> arest:Well=_ —- _____Foundat.ion Property., - - 1 <br /> SEEPAGE PIT [ l Depth---------.' -.Diameter-------------- ----Number---------- --F- '°" ,f "f Rock Filled Yes ❑ No <br /> RockSize-------------=-- -`----- ----•------------------ <br /> I Water Table,Depth----------------------------- - .. <br /> I Foundation--------- ------`.Prop. Line--------------------------- <br /> Distance�to nearest: Well---------------------- _ <br /> REPAIR/ADDITION (Prev:-Sanitation Permit ----------------------------- -- -------:Date.-.__-_.- :"----- --- ----- -) <br /> ----- -------- <br /> - = - _ . <br /> . _ <br /> Septic Tank (Specify Requirements)-- --"--� ---=----- ------ �� - <br /> Disposal Field (Specify Requirements)-- -- -- <br /> -------------=------------------------- <br /> --- ---------------------------- - ------------------ <br /> ----- - <br /> ° =-------- --- ----- ------;----------------------- ---------------- ---------------- <br /> ------------------- - <br /> - --------- - <br /> (Draw existing and required addition an reverse si e <br /> 1 hereby certify that 1 have prepared this application-and that the work will be done in accordance with San Joaquin-County <br /> ions of the San Joaquin Local Health District. Home owner or licensed agents <br /> Ordinances, State Laws, and Rules and Regulat <br /> signature certifies the following: <br /> f <br /> work for which this permit is issued, I shall not employ any person irs s <br /> "1 certify that in the performance of the <br /> uch manner as <br /> to become iect to Wo , n's. Com ensation laws of California.".. - <br /> -� —�- <br /> Signed <br /> �_ �` QtJ! — . --- ---- <br /> Owner <br /> t <br /> --- -- - ---- <br /> F •- f <br /> = / --------------- --- e :. r <br /> ," T 1 e <br /> BY <br /> , .A, <br /> f other than .ow ner) <br /> + 'FOR DEPARTMENT USE ONLY <br /> - �­ <br /> M ---- --------R <br /> ATEAPPLICATION ACCEPTED BY___"-" ._ DAT ..-- <br /> DIVISION OF LAND NUMBER.------- ---_- ----- - <br /> -------------------------------------------:--------------------------- -------- -------- <br /> - --------------=--------- <br /> ;. . <br /> ADDITIONAL COMM <br /> ---- <br /> ---------------------------- <br /> I ----- <br /> -------------------------------- _ <br /> --- - ------------------------------------ ------------------------------------- -------- <br /> Final Ins ection.b ------------------------------------------ <br /> --- Date,--7 ------------------ <br /> p y'-�""" � <br /> F&S 21677 R 6 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />