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FOR OFFICE USE: (/ t _ FOR OFFICE USE: <br /> i APPLICATION FOR SANITATION PERMIT <br /> k <br /> ----- ------- --------------------------- <br /> (Complete in Triplicate) Permit No.7?1.�-7._-47 <br /> --------------------------------------------------------- <br /> _________________________________________________________ This Permit Expires 'i Year From Date Issued Date Issued 4' <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 /> JOB ADDRESS/LOCATION----..-------,,,_, CENSUS TRACT------ -------__------_ ....-. <br /> s Owner's Name.......... %--------CZ-A._ ---- ----- ----- Phone <br /> , <br /> _ <br /> _ <br /> Address----- ,_ t OE- 1.1. ------------------ C i ty A --------- <br /> Contractors Name °--- -.+- -z-:--- ....%f,:. !- -:---• -_-----,-- License #.+ & Phone - - --- -- - ±_ <br /> Installation will"serve: Residence DJ Apartment House.❑ Commercial ❑ gTrailer Court ❑ <br /> �. . .F. MotelOther - ---- <br /> Number of living units: _.___,__Number of bedrooms:- Garbage Grinder-� ____Lot,Size...__ -- -.-_ _------------------- <br /> 1`7 <br /> ____________ _ __ <br /> Water Supply: PublisSys#err and name --- =�----- ��. ����t I l�� � Private. <br /> - .. <br /> Character of soil to a depth of�'3feet: S;ar)d ❑ Silt❑ Clay ❑ Peat 0 - ady Loam ❑ Clay Loam f& <br /> Harcip nEl Adobe ❑ .- Fill Material__._.____.._If yes,,t pe_� ___-___-_-__ <br /> k ! <br /> I [Plot plan, showing size of lot, I- ')If,system in relation to wells, buildings,'etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septi�p k or sepage pit permitted if public sewer is available within 200 feet,) -C <br /> PACKAGE TREATMENT -[ ] SEPTIC TAN) [:]—=- -� Size -»— - - Liquid Depth------------------------- <br /> Capacity— <br /> ___-___• _____ <br /> __Material--------------- -f <br /> Cap�acitYi�- "------ ---=---TYpa----•=.-=-=--�--==---- 1 � --------NoCompartments.-�-----='---------------------�--- <br /> _Distance to nearest: Well--------=------'------------- ----,-:,-----Foundation----------�=-:----------.Prop. Line---------------------------- <br /> t _ 4 i -- -- . -- f.�ti_ -----_------------------------ <br /> LEACHING LINE [ ] No, of Lines-_.-__,_____ __________ Length of each line._._______-__ ---_ __-_ ___.Total Length <br /> 'D Box . ......Type Filter,MatenalI-------------------Depth Filter Material_________ -__. )k_ - _____ <br /> Distance-to 1ne st: Well---d-,---------- -- ----_1=oundation__________________________.-Propett L°ane-_� - <br /> SEEPAGE PIT [ ] Depth IJiameter_ "E -------Number_ - ' Rock Filled Yes ❑ No ❑ <br /> Water Table-Depth ------------------ Z\1 ------------- ------------- Rock Size------ i------`-------------------�------------ <br /> t I ` 1 <br /> Dist ncce'.to nearest: Well--- _ ____ Foundation---------------------__.Prop. Line <br /> REPAIR/ADDITION {Preva Sanitation Permit#_.__-_-__------ -------------------- -- ------------Date---------------------------:__--. ___________) <br /> Septic Tank (Specify.Requirements)------ ---- ---------------- = --- ----- ---f--° ---------------------- - ----------- ------------------------------------ <br /> Disposal <br /> ------------------------- ---Disposal Field (Specify Requirements):------ --- --1 _ --- --- ,r.. _ j1 � G r -��C-------- <br /> ----------------------------------- ------- ! ' <br /> j - - ---- ----- - -- <br /> ---------------- ----- k <br /> ----------------- -- -- ---- ----------------- - - <br /> (Draw existing and required addition on reverse side) f . <br /> I hereby certify that I have drepared this application and that the !work will be-done in accoidance with San"Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the followiiitg: <br /> "I certify that in the performance of the work'for which this permit is issued,'I shall not-eeriploy�tiny person in--such manner as <br /> to become subject.t Wo yan' Compensation-laws of Cahforniq.'_'. <br /> Signed__ /'`r � ' -------- --- -- ner <br /> Ow <br /> ------------------------------------- <br /> By-------------------------------------- - ..... Title----:- � <br /> (If other than•.owner) }. _ ._q. ; <br /> ! .. ,.. FOR DEPARTMENT USE ONLY ` [ <br /> ' APPLICATION ACCEPTED BY -_.__ __-___- ' <br /> ---- -._ ..:------- -=------------- ----- -----�---------------- ------�-_--� _� DATE ----- -'J" _ �- ---=--- <br /> DIVISION OF LAND NUh148ER?_____________ _ DATE-------------- <br /> ---_-___--__- <br /> ADDITIONAL COMMENTS-------------- --- ------ -- ------------------------ -------=------------------ `----- ------- -----------------------------------------------{ .. <br /> t _f <br /> ---- ------- - - -------------- ---------------------- <br /> -�� <br /> Final Inspection b _ ____.___Date.___- - Z --_ --__._ <br /> FH 13 24 �SAN JOAQUIN LOCAL Y!EAL-T.�-,-DISTRICT F8s REV._Ind am <br />