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FOR OFFICE USE: V FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------j�--------------------------------------- Permit No.-7g7n/P,,7-_' <br /> u (Complete in Triplicate) <br /> -------- =----- ------------------ ------------------ <br /> Date Issued.-M:747%9__-�� <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 Regulations: <br /> ' - - - -- - - ---t�-----------'.------- - CENSUS TRACT t <br /> JOB ADDRESS/LOCATIO _�___.____ Q.___- _ q <br /> Owner's Name ---- � ,------- -- :__-.:..-- Phone -'_ <br /> - = - <br /> j " t <br /> Address- --- :.- --:-- City 3 3 "P6d <br /> ._ .___ <br /> Name- - = ': sd�'6?_:-AVIV ------ License #- 'T..+ ---Phone- -�tR -------------------- <br /> Contractor's f <br /> € _a <br /> Installation will,serve: Residence Apartmenf Rouse ; Com ercial Trailer Court ❑ <br /> .: Motel ❑ Other - t - s <br /> -- -- -------- ----- - ------- <br /> Number of living units:_s,__� ______Number of bedrooms,-- ";_,.Garbage Grindw.._:__..._,.Lot.Size---------l- 0_- -.•__________ __.__.__..._. <br /> Water Supply: Public System andlrfame} <br /> : - <br /> :--Private <br /> ----------------------- - -*----- , r <br /> Character of soil to a depth of 3°fe0:/ Sand ❑ Silt❑Clay E-1 Peat❑ Sandy Loam Clay Loam <br /> 1 Hardpan❑ ❑ , Fill'MateriaL.._ If yes, type ------ <br /> f <br /> (Plotf;plan, showing size of lot, location of system in relation to wells, buildings, etc, must be'placed on reverse side.) `�- <br /> � <br /> NEW lWf,44ATION: (No''sepfic tank'or seepage .pit permitters if public sewer is available within•200-feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK ' ize _:<- f p <br /> 1 Liquid Depth!,. <br /> `..� T -6 -._T e._+ ---.Ailaterial ._ _-----No. Coirnpartments-.--+ ---,_h}----------------- a <br /> ,V Capa city Yp r r'. <br /> � or>-- `t J_Foundation- - -_ .__�_._--- •:Pro . Line.---S---- <br /> -of <br /> ine.--S- `-----" <br /> LEA Dist ince-to nearestrWell.__,_-_.t..___.-, __ p <br /> LINE [ Na.;of-Lines __._'Z'�.y .�__ Length of each line., . , <br /> { n� 6 =_. . -----.Total Length,:.../70- <br /> g y <I � ox.-� Type Filter Material-_- Dep€h Filter Material---,_ __ te:jf <br /> -_._r --.t .. _ <br /> r <br /> Q I .._ <br /> y _ <br /> GOf3-°----- Foundatl�on------ --------- Property Line---- - - --=-,----- <br /> `•�-�•Distaraca'to nearest:-Well�t__ ----------------- <br /> e�r_f- ------ - ._ Number.----- ! <br /> SEEPAGE PIT [�Q, De th /� - -_ s Z-- Rock Filled Yes1. " Not <br /> p � <br /> .... s X -. <br /> I Water Table'Depth- ; Rock Size< - ' ----------------- <br /> w— f!- <br /> .> Q �.t... ..x . .. - <br /> IDistance.to nearest:Well.=__!__ ---- .---___-___-! Foundation -------- ------.Prop, Line__-- ---_------------- <br /> REPAIR/ADDITION (Prev. Scinitation-Permi't#:- _-_---"------=------------"------------------- <br /> --Qate-----.•---.---------------- "-------_-_-1 <br /> SepticTank-]Specify Requirernents)-----'------------------ - ----------- -----=----- = ---- -------=------------------------------------------------------------- <br /> Disposal <br /> -------------------=------------------------------Disposal Field (Specify"Requirements)--------- ---- ------'.------------- ----------------------------------.----- -- --------- ----------------------------- ---- <br /> ----------------------------- <br /> -- <br /> I <br /> ' }- :e3 , --- ---------- ---- - s <br /> -------- ----------------------------------------------------------- <br /> " -- <br /> ------ ---------------= - -I`X� <br /> ----------------------- ------ - ------------ ------ ----- ----- $ <br /> ------------ -- <br /> " (Draw existing pnd required additio"q�o,�ry re,;v,R6 side) = Y "4 <br /> 1 hereby certify that I have prepared this application and that theCw,ork,willr,•be-idone in accord an{ �vit��an Joaquin County <br /> Ordinances„ State Laws, and Rules and Regulations of the Sart Joaquin Local Health District. Home owner or licensed agents # <br /> signature certifies the following: ►.. <br /> "I certify that in the performance of'.the work' for which this pereiit is issued, I shall not employ any person in such manner as <br /> to become sub[ect_.toLWorkman's_Compensation laws of—California." - 1 <br /> Signad-' ' t. = - Own _ t <br /> r. }_ .,. t ea- - -7er <br /> r 7 e, <br /> r <br /> If•other than owner) <br /> -FOR DEPA T NT USE NLY <br /> APPLICATION ACCEPTED"-BY--- ----- ------ --- ------------- -------- DATE J d -°7a-- -= ----- <br /> DIVISIONOF LAND NUMBER --------------- d---- ---- ---- ----------------------------------------- -----------DATE.-----------. ----------------------------------- <br /> - F <br /> ADDITIONALCOMMENTS------ ----------------- ---------- ---------------------------------------:--=- ------- ---- ----------- ------- ------------------------------------------- r <br /> IP I <br /> - - --- .. <br /> = -- <br /> ----------------------------------------------------------- - <br /> - ------ <br /> Final•Inspection by:----.(/�.._-- - - __-- - _ - Date_ <br /> ---------------- <br /> EH 13 24 SAN OAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/ 3M <br />