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FOR OFFICE USE: FOR OFFICE USE: <br /> I APPLICATION FOR SANITATION PERMIT _ <br /> -----------------------------------------------------' <br /> (Complete in Triplicate) l` <br /> Permit <br /> t <br /> This Permit Date Issued____________________ <br /> _____________________..___._.__._._.._._..__.__-- Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andinstallthe-work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION-_--_ ------...__ _ - .7.�-- ........ P., �_I G n <br /> - � __. w_ .CENSUS TRACT <br /> Owner's NamePhone <br /> Address- ---------------- ! r �� " �� jQ C� Idlll�,<17 'L°:( Zip-7"K-` J�,.9.07,F--- <br /> ntractor's <br /> Contractor's Name • r(��- . .:. - -- -- icense . /?_- -___Phone_ - - ----------- <br /> Installation will serve; Residences Apartment House [:] Commercial ❑ (Trailer Court ❑ <br /> --•i Motel ❑ Other--=---------------------- ,:.. b. <br /> Number of living ants: / Number'of bedrooms Garbage Grin' '_Lot Size. <br /> C <br /> Water Supply: Public System and:name------------ --'-:-------- ----------= `. = Peva <br /> } - I Y - _ - to <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt[] :Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ � Adobe ❑ Fill tei;irJ F.. ____If,yes, type _____ ____ ____ _____...__._ <br /> of �. i1j, <br /> (dot plan, showing size of lot, location of system in relation o�rwells, b�ldings e-etc-must'b-e-piacyd-o-reerase sE e.1 I <br /> PACKAGE INSTALLATION: :'(No? <br /> � •(Nae SEPTICtTANKr -see a��: it f�ize � •- d public` � s available within 200 feet,) <br /> p p g p permitted if sewer i <br /> [ 1 [ 1 : � e ' ------------------]-----Liquid Depth _- -I_ - ----•-- <br /> Capacity/-P 11 -------TYPe'�i -- , P # <br /> - Material.' - - `: :_No. Compartments.-: _ <br /> Distance to nearest: Well.------ ----.. --------.-----''----'----Foundation.44.---- Prop. Line- - -____-- -- <br /> LEACHING LINE [ ] No. of Lines..'__ errg#iz-1-of ea � ina- _ ________________Total Length-------- <br /> D' Bax YP Depth F11#er Material. ' ----------------------- <br /> -- <br /> • Distance to nearest: Well--'' �----,-_--� .. .Y . . .. . -- - '-- -: --------- -; � <br /> :--Type Filter Ma#erial_' ,1� <br /> Foundation _ ' <br /> . , -,,�_ ..:....._, � -_�._;.;----------Property Line--=__��__~.�.�-----'--- _ - m <br /> P oyer s � - <br /> SEEPAGE PIT [ ] Dept <br /> h ';g----D'iameter- ___ _,--,�NumEer........ ; Rock Filled Yes No❑ <br /> Water Table Depth.--- -----------'------=--I-------- :..---:------ Rock Size------------------------------------------------ <br /> Distance,to nearest:Well_:._._; ] � ___:_:__ <br /> fou a on i - rop. Line <br /> REPAIR/ADDITION tcluirements) <br /> v. Sanitation Permit#- --------------------------------- --'Pae 1__•`,_ -•------------------:------.-----M E <br /> Septic Tank (Specify ---- -------- ---- J- <br /> -- " = `J- = = <br /> -- <br /> ` Disposal Field (Specify Requirements)---=--- ------ ----- - ------------------------------------ -�� ' <br /> -------------------------------- ---- -------=---------- -------------- ------- - -------------------- - --- <br /> - <br /> . <br /> �(Drclw existing..and-required addition on reverse sided ( t <br /> hereby certify that have prepa ed this app€lication-and that-the work will 'Ise done5in accordance with San Joaquin County <br /> Ordinances, State Laws; and Ruhes�and ,Re ulations of the;San Joaquin Local Health Distrix; Home owner or licensed agents <br /> signature certifies the following: AL <br /> tr"ra i <br /> I certify that in the performance;of"the work for which this permit is:issued,! shall tiernploy any person in such Manner as <br /> to become sub'ect. rkm n's mpensation: laws of .Califar,,ilia.':_. ...--.�., <br /> i.. <br /> Signed ---- ---- ----Owner <br /> ,. ------------------ <br /> By-' <br /> Y --------- ----- - Title----- ------=------=-------------------------------- ------ ------- <br /> (if other than`owner) <br /> t --FOR''DEPARTMENT USE ONLY: <br /> f <br /> ' APPLICATION ACCEPTED; BY_° `- - ----- ,• ' - -----------------------------------------------------' -----DATE.--�7__ -�M ---------------- -- <br /> DIVISION OF LAND l�grBER.` . .dam- - .z. ` " DATE ' <br /> ----- - <br /> ADDITIONAL COMMENTS. '*. _, -�` ------------ <br /> - - --- �r__ <br /> - <br /> ----- - = - ----- -- ------------- ---- --------- ------ -- �j ----- - ; -- <br /> Findl�I sfi pection 6y -� _ _. ..... . ----- --- --Date / 1 ---�---------------- --- <br /> EH 13 24 \ SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />