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POR OF� USE: APPLICATION FOR SANITATION PERMIT Permit No: ---•(Complete in Triplicate) 3 `, <br /> ------------------ <br /> .:\------ ----------- <br /> --------------- <br /> ------- (Comp Date Issued <br /> Expires 1 Year From Date Issued <br /> -------------------------------- <br /> ------ ----- --- --- --- ------- - ---- --- --- --- -- This Permit Exp' _ <br /> ' a <br /> ---------- <br /> - --------------------------- <br /> -- ermit to construct and install the work he. <br /> uin Local Health District for a p Rules and Regulations: <br /> Application is hereby made to the San loaq compliance with County Ordinance No. 549 and existing <br /> App ovj�",*j 0" --------------- ---- -- <br /> described. This application is made in compo <br /> n� t/f ``7- , r. rr.' # ,c�� CENSUS TRACT <br /> .�r ;t� <br /> �D$�---• --- - �f,-- --- ----------------------- -- -------- -----------------Phone ------ - -�=-----------�- -- <br /> JOS ADDRESS/LOCATIONr�+ . ----------- ----- _ <br /> Cit "� " <br /> Owner's Name ------ Y <br /> l {' ,-------- ------------------ Phone ---------- <br /> ----- <br /> Address ---- - t'"" License # --"` <br /> �, ----------- Trailer Trailer Court <br /> Contractor's Name _._"_- --- --- -- -"- Apartment House�[] Commercial ❑ <br /> Residence 1 P <br /> installation will serve: _____-----_--- i <br /> 'Motel ❑Other <br /> Garbage Grinder '��-�-�`�- -- Lot Size --------�--------------------- <br /> --------°---"- -•- <br /> Number of units:-__--�----- Number of bedtaoms -_----- --- <br /> ----- - <br /> ---Private c� <br /> -- ---- ---- ---- <br /> Water Supply- Public System and name --------------•--- - -`-- Peat❑ Sandy Loom ❑ Gay Loam ❑ <br /> Cr <br /> Character of soil to a depth of 3 feet: '; Sand'❑ Silt❑ Clay ] <br /> Fill Material -------- --- if Yes,type <br /> ------ <br /> Hardpan El Adobe [I1 <br /> etc. must be placed on reverse side.) <br /> (Plot plan, showing size of lot, location of system <br /> in relation °f publ�bsewer gisravailable within 200 feet,l ' <br /> NEW INSTALLATION: (No septic tank or seep g ,p permitted ____.____.__- <br /> Liquid Depth -- `""' <br /> SEPTIC TANK'[ Size--------=`---- - <br /> PACKAGE TREATMENT [ ` )' '•} iNo. Compartments --- -------------- <br /> -Material--= =' + <br /> Capacity �i � '" .4 TYpe-. r: `___ -_. � Pro Line _ "G"x <br /> Foundation __ p t <br /> Distance to Weare Well ) ---- $ <br /> Total Length J-77-0 -- -----•-� <br /> LEACHING LINE [ ] No:, of Lines -----� <br /> _ Length of each line_---- <br /> { Depth Filter Materia <br /> --------------- <br /> --------------------D' Box -4- ..- :-- TYpe Filter MateriaProperty Line - --"'� <br /> f - _ Foundation - ' -- ' " p <br /> Distance to nearest: Well " "' - <br /> t No i0 <br /> _ --------- �ek 'Billed Yes <br /> Depth ---�Er-- ----- -- Diameter --�--��` Number ---- ------ - -- <br /> SEEPAGE PIT [ ] p -s' <br /> t • :Rock Size - - <br /> ------------------ - <br /> ----- - - <br /> Water Table Dept -:d -- ;... <br /> Distance to nearest: Well ___!" '-`'�f- f ` <br /> ...Foundation '- ----- Prop Line -.--------- <br /> s <br /> --:-- ---- Date = ) <br /> REPAIR/ADDITION(Prev. Sanitation PermE; f---- _- _---____ <br /> ------------------------------- <br /> ----- ----- <br /> Septic Tank (Specify Requirements) - = -- ------"---• ----------- - <br /> l `---------------== ---- <br /> E Disposal Field (Specify Requirements) -------- <br /> �� , j <br /> I ------------------ <br /> ----------- <br /> r -------------- ----- <br /> -------- ----- ---- ------ ---- <br /> -------------------------------------------------- <br /> ------ ----- ----- ------ -----(Draw ex�stin a ---------- ------ ----- "---------- ------------ ---- <br /> nd required ---- - -- s <br /> --------------------- - ----------------------------------"•ra - e : . "g_:.; eq dition on reverse side) <br /> j'� 1 <br /> h San <br /> certify that 1 have prepared this application and that the w°Joaquin LocalMeal h D str ctn <br /> ilt be done in accordac <br /> I hereby Y Home towner or Joaquin <br /> c „ <br /> en <br /> County Ordinances, State ,Laws, and Mules and Regulations of the San q <br /> sed agents signature certifies the following: '' arson in such manner <br /> "I certify that in the performance of the work for which this permit is issued, I shall,not employ any p <br /> as to becom ubject to Workman's ompensati.on laws of California." <br /> .�„ . <br /> f feq'set =- ,:�: Owner <br /> Signed Title --- <br /> ----- r <br /> 3y --------------- <br /> other other than owner) I FOR DEPARTMENT USE ONLY---------------- <br /> y' <br /> i <br /> ,�� .. ---------- <br /> ACCEPTED <br /> + DATE <br /> ' ----------- [-- �--- r�:_ <br /> APPLICATION ACCEPTED BY ------ 4 ci = _._. ._-W._--- DATE ---------------------------------------•--- <br /> BU1LDlNG PERMIT ISSUED ----- ---------------------------- --__- <br /> _______________________________________________�r.- .-___ "_.__-__-_____.._______-__ ____-_____-_____-____-_---------- <br /> -------------------------------------------- <br /> . <br /> -------------- <br /> ADDITIONAL COMMENTS --------- -------- <br /> ----------------------------------- ------------------------- -------------- ------- ------------------ <br /> ----------------------------------- -------- <br /> - ---------"---------------- <br /> -------•-- ate -------- ----- ---- - --- ----- -- <br /> Final inspection by: ----"-------------"-------- <br /> SAN .10AQUlN LOCAL HEALTH DISTRICT <br /> ,. I eco ne,. SAA <br />