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R OFFICE USE: R !� r FOR OFFICE USE: <br /> FO APPLICATION FOR SANITATION PERMIT <br /> �..� �. r <br /> t (Complete in Triplicate) Permit No. <br /> _ ._ . <br /> -------------------------------- Date Issued.. 7n/:-:0 <br /> .7g <br /> I-IV <br /> D---- ------- <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,kegulations: _ Y <br /> JOB ADDRESS/LOCATION-...-- - --- ----- --------------- <br /> �.. CENSUS TRACT . -. <br /> Phone:-, --, <br /> Owner's Name -;/:1-a- w o ----- -------- --------- --------- <br /> ------- --- i <br /> -----=----------------- -- ---- <br /> Address--- r = - --- -City.: --- <br /> Zip ' <br /> Contractor's Name-'-- -{i - --------------------------------- ----- -cense # --i e -------- <br /> Phan <br /> _ <br /> � <br /> Installation will serve; ,, Residence Apartment House ❑ Commercial ❑,•Trailer Court ❑ <br /> ' > Motel ❑ ..Other .----- -------- <br /> _/,7, ,5 <br /> - -_ / <br /> �.7 <br /> Number of living units;-_0- /--, <br /> Number of.bed rooms`': Garbage Grinder ._----T-Lot Size-. . --- <br /> r �j .�� - ---------------------Private ❑ <br /> Water Supply: Public System and namJC : 111 - - - ____,- . _ i <br /> Peat.❑- Sand Loam Clay Loam <br /> depth of 3 feet: Sand❑- -Silt El CIO ❑• u. .Y <br /> Character of soil to a de Hardpan E] Adobe Fill Material--_-----.---If yes, type-------------------'--- <br /> [Plot plan, showing size of loft, location of system in relation to wells, buildings, etc,must be placed on reverse side.} t <br /> NEW INSTALLATION: :(No,septic tank or seepage :pit permitted ifpubli sewer is available within 200 feet,] <br /> Liquid Depth - <br /> PACKAGE TREATMENT' ['} SEPTIC TANK [ j Size' =--- <br /> --- ---------`-------Type----'--- ------ ----Material = = No. Compartments------------------------------------ <br /> Capacity , <br /> LEACHING LINE [ ] No. of Lines------------- -- -------., Length of.e c <br /> - Foundation=----- ---------------------Prop. Line_;------------- ------------ YC <br /> .,Distance to nearest: We -,.._--....__ <br /> . I � --'._.--,Total Length------------------------- �------- <br /> .._. - each line.---- . ------ --- <br /> [ • to -Type Filter Material-------------------Depth Filter Material.------------------------------ y; <br /> D' Bax. Foundation -------- ----------- .Property Line----------------- ------------------- <br /> :Distance <br /> l <br /> nearest; WeIL=----------- ------ - „ ,�,,...__,•.,-„_ � a <br /> SEEPAGE PIT [ ] p t ..Diameter..--- -_ .Number- ----------- ----------------- Rock Fi11ecJ Yes ❑ <br /> No'❑'� <br /> Water Table Depth - Rock Size... ---------- t <br /> 1 Distance,to nearest: INel1 ---------------°--------------------Foundation..,-- ------------- ------ <br /> ------- <br /> Line <br /> REPAIR/ADDITION (Prev. Sanitation.Permit#------------------------=------------ Date =- 1 <br /> y ' <br /> Septic Tank (Specify Requirements)- -}--- ---------------------- ---- <br /> ------------ <br /> Disposal Field,(Specify Requirements)__- ® -- _elkf �----- <br /> 1 ------ -- <br /> 1 <br /> --------------k---....'_...--'. -----.�....._----....---....--_--.-....__._-...__-....___-.-. ____..__.-...___-..____.... <br /> - I - ---------------------------------------------------------------------" M1 __:.--_.__. <br /> 1 <br /> .....:.... ......-------------------------------------------__...._ f .� . <br /> r L l (Draw existing•and required addition-on reverse side} - I 4 <br /> I hereby certify that'I have prepared this application and that:the .work will be done in accordance w,'sth San JoaquinCounty <br /> Ordinances,. Stc tel Laws, and-Rules and Regulations of the San Joaquin Local_ Health District. Home owner or licensed agents <br /> I signature certifies-,the.following'.- _ <br /> "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 becom bject to. W an's ompensation laws of California:" <br /> I— �p <br /> Signed---� --------- <br /> Title <br /> -- �L : Ownsr } <br /> B itle--- --- - --- ---- --------------------- ----- -------- ----- <br /> Y <br /> T <br /> [ t ---- <br /> (if other than.owner) ' <br /> I ] FO DEPART NT USE ONLY # <br /> �....... --------- ---- ----- <br /> APPLICATION ACCEPTED' BY------ - --- ---------- ' <br /> DIVISION OF LAND NUMSER`4 --i---- -- - �..,; DATE. ; <br /> t ------------------ <br /> ------------- <br /> ---ADDITIONAL COMMENTS---------- <br /> - - 7------ - _ <br /> ------------- <br /> ----------------- <br /> ----- <br /> . __-- s <br /> __-...__-..__.... <br /> -"-----"...----...._.___-_-__-.. <br /> -...-___.------------------- ------------------------------- -. ----------------------- <br /> ----------- ---'------- _-_.... __� <br /> - <br /> .---..-__ <br /> ..-__-... _-.. <br /> -------------------------- <br /> -..___ .--------------------------------------�- r T <br /> _.- __ .. --- - <br /> Final•Inspection by:... ----- -'-Date. <br /> ---------- ----- ---- -- - <br /> h <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />