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FOR OFFI_GE SE: FOR OFFICE USE: <br /> fid APPLICATION FOR SANITATION PERMIT <br /> 7 .. � <br /> (Complete in Triplicate) Permit No.. ._.. ... <br /> ------------------------------------- ------- --------- - ---- \,.k - i <br /> .� <br /> ."`-^•�-�-•�-r-•-.��. Date Issued-�-1-��" <br /> ---------------- ---------------------------------------- This Permit Expires 1 YeW_fr*m Date Issued .. <br /> t <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 /> ------.CENSUS TRACT_----.-'-- --- --------- <br /> JOB ADDRESS/LOCATdON / <br /> wPhone_p�l � ��-7O • C — <br /> Address ` r �--- = Ci - --- -Zi <br /> Contractors Name.. . ......... ----------- ------Lice n s e #- .:34 _.Phone.-.Tim. <br /> F <br /> Installation will serve: Residence 2-�- Apartment House.❑ Commercial ❑ Trailer Court [] <br /> y. . _ _ . . 'Motel ❑ Othejr - - -------- --- = a f <br /> Number of living units ,;tom ''.'�..Nurriber of.bedroorxis......._:. Garbage Grinder3 Lot:Size----- --.. - -".-. _,_ <br /> r r name '.'.� r =-�:---------- ---------- --- ` - --- Private <br /> Water Supply; Public System c�nd name , -- <br /> , <br /> Character of soil,to a depth or,3'feet: Sand [�.`SiIt�O Clay ❑ Peat ❑ Sand'y Loam ❑ Clay Loam El. a ; <br /> s % Hardpan ❑ -Adobe ❑,`"Fill Material---.--------If yes, type--- ............................ <br /> < <br /> (Plot plan, showing size of lot, location of sys`te�m in relation.to;wells,'bu11dir— etc.must be placed..on reverse side.) f <br /> NEW INSTALLATION-— -`(No`septic.tank,or seepage pit permitted if public sewer i; available within 200 feet,) rr 4 <br /> PACKAGE TREATMENT [ J SEPTIC TANK '' "'Size_-_:_- ---- <br /> X.V-- - '.... ..................Liqu"icJ Depfh._ _ ___ . -_ <br /> - ----------- <br /> Capacity-/ �-------:Type..l �#'_ ..:_._Material.--5 9 -- No. Compartments.-i-----.--- --------------- <br /> 1 r � = ` 1 = r <br /> Distance.to nearest:.Well_'_.___ O:--------------_-------_---Foundat.ion,:_. _...:>:-------=Prop. Line--------------_.._ <br /> LINE; No. of-Ernes ._�------------------Length of each Bile 5rQ ._ -©_-----.Total' Length _:___�.�_.--------------------- <br /> LEACHING ._. <br /> _. _ _� <br /> ;D' Box_-'_%• --Type Filter Material. ..-.____..Depth Filter M�terial.._..� .._ <br /> _ ----- - <br /> Distance..to nearest: Well--: -: Foundation..._ <Q 'E ....Property Line ___ Y•----- _______-. <br /> t. s <I,,c, _ _ <br /> SEEPAGE PIT Depth , -� -_ _Dia'meter._,._.�e___u Number �____� ��, , - Rock Filled Yes No ❑ <br /> P -------------------------- A------=--- Rock Size_- - � ,� -------------------- <br /> . �r <br /> Water <br /> ' -- --------- f' ,� .� - '1 <br /> D scan a Col neaeesh: V+/ell- '- ---,ld ----7----------------- <br /> - Foundcftion-----fD--------------Prop.tiLlne-_'" --.--_----------. <br /> ---- # \I <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-_.-..____:.:'_____________________________;.._._:Date ..::__.:�._....._....._.._._... ) 7 <br /> Septic Tank (Specify'Requirements) :.. - ------- <br /> Disposal <br /> --- <br /> Di s osal Field (Specify Re uirements `---.---`------ ------ -------!! -------------------------------------- -----------------=-----------------------' ----- ----- ---------------- <br /> P � I p Y q ) � 1 � �-__•� ��� l <br /> ------------------------ - - ---- ------------------------------------------------ ---------`----------------------------------------------------- ----------------------------- <br /> _ _ <br /> 1 (Draw existing and required addition_onr�Rverse side) <br /> hereby certify that:l hd"a preps ed this appjicationand that the work will be done in accordance with San Joaquin County <br /> Ordinances,' State Laws, ancl- Rules and Regulations !of the San Joaquin_ Local Health District, Home owner-or licensed agents <br /> signature certifies the following: : <br /> "I Certify that in the performance of, t e work for which this permit-isNissued, I shall not employ any persen.in such manner as <br /> to become subject to Workman-ss Compensation lawstof California." <br /> a l <br /> Signed -" -- -- -- - . F'` 3 Owner <br /> ----- <br /> By-! �;.`�4/.."... :.Title. ---- - ------------ <br /> ------ . <br /> Y s - --- s ri 4 <br /> lfGoth�ek tangy owner) .. . .. : ti.. <br /> R'DEP T ENT SE ONLY f t---:( <br /> APPLICATION ACCEPTED BY : ----- -`". ----------------'- ----- a <br /> ISION OF NUMBER.' <br /> . - <br /> _ <br /> ; DATE � __. ..#. <br /> ADDITIONAL COMM Ts ---3 - -- <br /> ' <br /> q_ -�� -------------------------------------------------- ---------------- <br /> ----------------- -------------=--- --- ------------ --------- <br /> J - <br /> Final Inspection,by:_-- = ==" ` - Date. --1`" ------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M ' <br />