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i <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------- ---------------- ---- ----- (Complete in Triplicate) Permit No.---- -- - --- <br /> -------------------------------------------------- ----- <br /> --------------------------------------------------- -----I �� 1 Date Issued_.__. ..._� <br /> ------------------- ------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made tb.-tlie+S`an�Joa lUn Local Health District for a permit to construct and install the work herein described. <br /> This application is made in co'4plionce with County Ordinpnce No. 549 and existing Rules and Regulations: i <br /> JOB ADDRESS/,LOCATIO -_.� i _ �- - d CENSUS TRACT.------ --------------- <br /> ------------------- <br /> ------ <br /> ------ .--= <br /> - -------- - <br /> Owner's Name Y.�L .c� -`. -.t..------ --- ---- ----------- - -_ P h o p,. <br /> An_45_ 2 <br /> ne .. <br /> f. ��- :ht 1�A 4-+_ Z...__City -----Zip-----------------=--- <br /> Address--------- ----`---= -- -r <br /> .. <br /> ctor's 'ame____._____ i_ C _- ."` _ __`.�I�`,_ `f"-_ ____ J_.__- License #_ `---_PhonefsC� ._. C3�, ---- <br /> Contra <br /> Installation will serve.: sider*e- —Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> t ' ..._.•i�a Motel ❑ Other __:__.a_ <br /> ._ ---_ - 9 <br /> 'Number of livi g_units:__ �,✓__� Number.of bedrooms' -__,.____.Garbage Grinder------------Lot Size----- _-- ------------------�`� <br /> Wateri pp y e Syst m and name---- ------------` ----------- --- .--:. --------- -------- Private ' <br /> 5u I': Pu li __. l: <br /> Character of soil oto depth of 3 feet: ' Sand ❑ ?Silt❑ Clay ❑ : Peat❑ Sandy Loam ❑ Clay Loam <br /> �. �--� zrrdi ❑�""A�`obe "FiTI Nlater�af-- --- ----If.yes, type-- ------------ <br /> +Plot plan, showing size o 'Iot,ilocation of system in relation to,wells, buildings, etc. must be placed on reverse side.) <br /> ;NEW INSTALLATION: �(No septic tank`or seepage pit permitted if public s we is available within 200 feet,) <br /> it <br /> PACKAGE TREATMENT ["� <br /> SEPTIC TANK ize____L!.-_-- ------------------=---'------------Liquid Depth;_- _____._,___�. <br /> `kk P _ <br /> ________________ _ <br /> it <br /> Type:- N;---- _Material---L�- ------- --- -----No. Compartments------- ----- <br /> ' �I �s Le©th of eac line Tota) Length........ <br /> op. Line <br /> �.� Dis nce.to nearest: Well_... ._.__ ........ I Foundation--_-_- -- Pr <br /> LEACHING LINE K- Noa Lines -. C0 7V----- -- 9 ----_.(7- J----------------------- <br /> OT *-------------- -- p <br /> Ri _ ff e <br /> 'D'`130 w --Type Filter Material_ �_ Depth Filter Material___[ __ ___________________________ ___ __________Q <br /> - <br /> Distance Barest:Well._ _ ©i Found` /,-------- <br /> - tion.:----- '.� ---------.Property Line ., <br /> SEEPAGE PIT ( I.Depth_�-------;-------Diameter.__' ��f----------`------- l [[X -------------- <br /> / A <br /> le ❑ <br /> Rock Size Yes `o <br /> ' Number.----°-- -- -- Roc i ed <br /> Wdter'Table.Depth---- - ,.---"__ AZ <br /> --- <br /> II - � <br /> Distance to nearest: Wel1_._.�t_�0- ---------------- Line------- ---------- --- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#t; -_ .--------------`------;=---------=-- <br /> f �p� <br /> D ' --- ----_--------------- <br /> ------ <br /> Se <br /> ----- <br /> SepicTank (Specify Requirements)f - = _------------- -------- -------- ------------------- <br /> Pt <br /> ----- -------- <br /> rDisposal Field (Specify Requemeiltls) )/ - = ---------- <br /> X. <br /> ) <br /> - - = <br /> E ° -- I- ' U----------------- - - - -- ------- ----=--- =--------- ---- -------=- --------- <br /> -----i------------ -------------- _. -' ---------------------------- --------------------- <br /> ---- ------- ------- <br /> I {Draw existing and required addition.on reverse side) <br /> I hereby certfy.that� 1 have g4par�d this application and that.:the-work:will -be done in accordance with San Joaquin County <br /> Ordinances, State Laws,'�an- Rules 'a`nd�R ulations of the; San Joaquin Local Health District. Horne owner or licensed agents <br /> signature ce?tidees the following: <br /> "I certify that in the performan e[-of the work for-which this,permit is issued, I shall not employ any person in such manner as <br /> to bec su 'ect o orkmanbs Compg�sation .laws of: aifornia." <br /> Signe+,,.: . t ' .._ l� t. :�4 F- -�' &------ <br /> , . <br /> BY- <br /> ---Title._ <br /> - 4 <br /> , . <br /> (If other than':owner) <br /> s 3•. - - FORM DEPARTMENT USE <br /> APPLICATION ACCEPTE6 BY_:i --- - __-V -------------------------- <br /> ----------------DATE - <br /> DIWISION`OF-L'AND NDUB --- - -----------=------=----------------------- ---------------------DATE------------------ ------ --------- ------ <br /> ---- <br /> ADDITIONAL <br /> ---- .--=--- - ------ <br /> ADDITIONALCOMMENTS. ..... .. '��---------------------------- -------------------------------- -------------------------- --------------------------- ------------------ <br /> M <br /> -------- -------------------------------------------- <br /> ------ <br /> -----------------------------------:_ - ---------- _---------- ------------------------------ -.---_---_-_---_-_-_-_-_-_-_-_-_-_-_-_----------- ------------------- ----------'------- <br /> ---- <br /> __._---`-----------Date-.---- -�r.- _.- ------------------- <br /> Final <br /> dnspection by ------------------------------ <br /> EH 13 24I SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 9 /7e 3M <br /> yl <br />