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_ F,QR OFFICE USE: OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------ Permit No----- 1 Z <br /> ----------- <br /> (Complete in Triplicate) _----------- <br /> --------------------------- - ----------------- <br /> ��� Date Issued--- 7 <br /> •-------------------------------------- --------------- This Permit Expires it 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 Ordi ante No. 549 and existing Rules and Regulations: t <br /> i <br /> JOB <br /> IADDRESS/LOCAT ON--.-- W-- _ -- <br /> . CENSUS TRA ------ --- <br /> Owner's <br /> Name e. f - <br /> , -- -------- ---- _._---- <br /> q <br /> Address_ __ 11111$ ` <br /> --Cit'- <br /> Contractor's NamePhone---'5/1 i <br /> !. License #- _7l S', ? ---- S'��? 1t�F _. <br /> 41 M . =. ._ ,.._._.t.. C <br /> --------------- <br /> Installation-will serve: Residence (�`,Apartment House ❑,,- Commercial Trailer Court ❑ <br /> f Motel-E], Other <br /> Number of.living units-----------------Number of bedrooms' ,___Garbbq�ge eri-nder--.-.___._=.Lot.Size-.-:_ _ _ <br /> Water Supply: Public System and`name---- = -- 4- '"' 4 ----------------- Private �❑ <br /> r <br /> f.. .. . <br /> t <br /> Character of sail to a depth of 3 feet: ; Sand Eq—Sil.t4❑--C-lay-2—Peat•E]--Sandy-L-oam-❑----;-C-lay-L-oM ❑ <br /> :Hardpan E] I Adobe Fill Material___------------- <br /> If yes,type>__ ------------- ______________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.""Must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank'or. seepagetpii permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANKA/[ ]"' .i . ,-_.. •Size---------------------------------------------------------Liquid Depth-------- --------------- <br /> [ t No. Compartments x <br /> Capacity ......... - _ ==TYpe ` ' ;_. _ r_-.Material ----------------------- <br /> i - <br /> Distance to nearest:.Wei 1_1----------------- ----------=--------Foundation-_..-------------- ----Prop. Line : -------------------- <br /> LEACHING LINE. No. of Lines-.------------- i----- Length of each line--------------_--------------____Total Length-------------------- ---------------- <br /> .'D' <br /> }__;D' Box-----.-__---Type Filter Material-------'------:---- Depth Filter Material--:---------------------------------- ---------- <br /> t,... . .. ..: I , <br /> I Distance to nearest: Well________________ ------------Foundation-------------------------- ,,Property Line---------------- LIE <br /> SEEPAGE PIT [ ] Depth----- ---------Diameter-- ------..____`____Number-----_.___ ------ ____-_--_____- Rock Filled Yes ❑ No <br /> Water Table'Depth --- --------------------------- -_-Rock-Rock Size------------ ---: ------- ---------- lr• <br /> Foundation--"' ' <br /> Distance to nearest: Well_._____ __.Prop. Line------------------------- <br /> ------------ _.p <br /> REPAIR/ADDITION {Prey. Sanitation Permit#--'------------'--=----------------- <br /> ---------------Date------ ----------- '-:'---`-------------- ) <br /> Septic Tank (Specify Requirements)____-_ _ t� <br /> _-:-_-- p-' --- ] ` <br /> Disposal Field (Specify Requirements) C_ <br /> ------------------ . - <br /> _. <br /> _. <br /> - ----------- ----- --- <br /> ('Draw existing and required add ition-on'reverse side) ` <br /> hereby certify that I have prepared this application-and that the work will be done 'Iin accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules land Regulations of the San Joaquin Local Health District. Home owner or licensed agents ' <br /> signature certifies the following: <br /> "I certif that in the p , Is _. t l <br /> y� Iierformance of the work for which this ermif�is issued i •shall not employ any person in such manner as <br /> to become sub' to., ork s CL pensation laws.of California.". �'� F <br /> g ' s E <br /> ------Owner <br /> Signed-' ` <br /> BY - - - --- Title.---EIZ-----=------------- <br /> - $ <br /> (If other than.owner) - <br /> f DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED' BY---- ------------- -DATE:-___Z..- <br /> DIVISION OF LAND NUMBER - ' . DATE t <br /> .E .. _ .. ... ., <br /> ADDITIONAL COMMENTS_______ ___ ___ _ / I <br /> r ------ ------------------------------------- -- - ------------------------------ -------------------------------------------- <br /> " -- --- -- --- <br /> 7 f� <br /> ------------------------ --- -------------- <br /> ----------------------------------------------- --------------------------------------------------------------- -------------- <br /> ----- ----------------------------- ----- --- ` ,` <br /> v <br /> ------------------------------------------------------ ='L <br /> Final Inspection by::-- . `�r "-='--"------------------- ------ ------- ---=- ---:---Date_ --t_._ ---`--� -- <br /> EH 13 24 r' �SAN.JW <br /> OAQN LOCAL,HEALTH DISTRICT,- FBS 21677E'REV. 7/76 3M <br />