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FOR OFFICE USE: -FORAFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -----•------ ------------- - Permit No. _�.-..�._�-�� <br /> (Complete in Triplicate) <br /> --------- <br /> - Date Issued--- 7 <br /> -----------_ --1,A- ------------------------------ <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: l <br /> JOB ADDRESS/ <br /> LOCATION: -i ::_'- -51 .....' �- '----- `---- -]---- ----CENSUS TRACT,------`- ----- ---------- ----- - <br /> Owner' <br /> s Name---- K -� ---- <br /> ----------- on 10� <br /> _. . , � etl <br /> - <br /> Address---- :�.3---- �'---------------- <br /> Contractor's <br /> `-- -- ::: � � -----------Zip ' <br /> city C' � t <br /> V=.it�N„`l.S.j'+:.. �_S4f.l�---•- ---- ----'----- -License #,5'� ---Phone ------------ -------- <br /> Installation <br /> Name_ - i <br /> Installation wi~II sere e: Resi ce ❑ Apartment House❑ Commercials' Trailer Court ❑ ; <br /> of iivin u.. <br /> Motel <br /> tbage Grinder -Lot Size ----- ----------------- <br /> ts:=.= -------- N . ber a �be rooms-------=---- q•-------=--- LL------------------ <br /> Number . <br /> Water Supply: Fublic System and a e = -: ... <br /> Private <br /> Character of soi to c death of 3 fee ` Sand ❑ :Silt 0 ,Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> ? .... <br /> I Hardpan Adobe s Fill Material__-_--- -If yes,type_ _`----------------..__ 7 <br /> (Plot plan, shoA ing ize of lot, loc t n of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLA 10 : (No septi ask ea---seepage pitgmrFt�ublic sewer is available within 200 feet, G _ <br /> t 5EPT1 TA K W Size---- =- - -----------Liqui ep <br /> PACKAGE TREA ME T [ ) <br /> Type-----------'1----_ _---Mater al_.-_ �4_ee_+Pdr_No:•Com artments--------- --------------------- <br /> T <br /> -------- <br /> i <br /> Capacity---{ ----- -----=' - - � :. -- P �----=----- -(� <br /> ! Foundation:€_,-,+- •-... Prop: Line--- ------ <br /> Distance to near st: Well__•..--_,l --- <br /> LINE No. -ofLi ___/-------------- Len 'th of each 11 a --------------. ------ -----Total Length.:-------.91'�- ---_ ---- <br /> _ g <br /> f ' <br /> pe Filter Material. ept' Filter Material . ............_ ________ - '---. <br /> Dista = rest: Well-_ -- -----Eoun ati. n---- s. ----- E___.Property Line-------A?_`----------------- <br />' SEEPAGE PIT [ ] Depths_ ` Rock Filled . Yes❑ No <br /> eter. Number ❑ <br /> a <br /> Water'tTable Der th----- - ----------------- Rork.. z <br /> ,T <br /> E,. .. , <br /> Distance.to near st: . Four n! - - .Prop. Line----------------------- <br /> Well ` . <br /> REPAIR/ADDITION ( rev. Sanitation Perm t#_-'---------- ----- -=------------- ----- -----.Date_.�.�----- '___--f <br /> --------- --- ------ --- --------------------------------------------------------- <br /> Septic Tank (S�pecif.y quirements) 3 <br /> Disposal Field {Specify — -- :-- � ------------------ --- ------ = -------------------------------- <br /> - <br /> --- :-----=-----------. <br /> - <br /> .......- ----- - --------------`-.._..'...__ --- -------------------- ___ , - _ r <br /> i <br /> } --------------- ------------------------___----------------------- <br /> -------- <br /> (Draw existing an qu1red add ion on reverse side) <br /> vim C <br /> hereby.certify hat I have prepared this application and-t_ at the war - ourt ty <br /> Ordinances, State Laws, Tad.Rules and Regulations of the San Jo quin Local Health District, Home owner or need agents <br /> signature certifies the Ilowing: •''� <br /> "I certifyth th performance of the,work for which this permit is issued, •1 shall not employ any person in such many as <br /> to becom sub ct' oW Co nsation laws of .California.'. <br /> Signed------- . ---- -- ------ -- -------------- --.--.- - ---- - <br /> e'r . <br /> ----------------------------------------------- <br /> (If other than owr er) ` <br /> "FOR DEP <br /> A t O Y b a` <br /> APPLICATION AZC TED BY------------------- -- ---------- ----------- -==-------- -- - D ----! - ---------- -----------. <br /> ATE'` '��"�� - <br /> DEVESION OF LAND NUMBER ---- -------- = ------- DATE <br /> - - <br /> ADDITIONALCOM ,ENTS-- ---- ---- ------------ ------------ -----------------=------------ --------------------------------------- ------------- ----------- --------- <br /> 5 t l_ - - --------------------- ------- - -------------------- ---- - ------ -------------------------------- <br /> -------------------------------------- <br /> ----------------------- <br /> - <br /> ------------------------ ---- ---------- <br /> FinalInspection-°by•.---------- ----------------- --------------------------------------------------------------------=----- ------------ 16 - R - <br /> Eli 13 24 SAN JOAQUIN LOCAL HEALTH DISTf T MS 21577 REV. 7/7h 3M <br />