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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR,SANITATION PERMIT <br /> {complete in Triplicate) Permit No.... .�.' d <br /> i ---------- --------------------- ------------ ------ <br /> A, 'Date�issued , <br /> ----------------------_-----------...................... This Permit Expires 1 Year From Date Issued <br /> �(t°w <br /> -� Application is hereby made to the San Joaquin Local Health District for a permit to construct and instasI he war herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and <br /> Regulations— <br /> 4. <br /> r `( sZr. "35 �{•;�;�}� tr �vT lyt4 "� - __` . NSUSTRAJOS ADDRESS/LO TI( � . _r ..---. ---_- �. . . . "' ffC'oT.s.. <br /> .__'----------------------_-.. <br /> t _..:.-: - - = --- ...................................... <br /> ! Address--Na-Rk-_f77...-- ;-----_----- �......'...--•--------------Ci _----- : ........................Zip-J? <br /> ti fj �! p /�� --- <br /> i Contractor's Name--'-- tG�[ -------- - - -:----�----------------------- ----_-------License #.'97)4 ./..._.__Phone_? -�_`_�le/�' _V4 <br /> �} •. - -. t_. �Motel-❑ �Other---.-----�--------- ----.,-i.--- -❑ Trailer Court.❑ • " . -.?� <br /> Installation will~�serve: Residence Apartment House Commercial <br /> 1 A Number of living,units:.....! Number of.bedrooms_._ .___..._Garbage Grinder.._;_,.._ 4 } .' <br /> /% 2Q_J <br /> ro <br /> ---- -•-Lot,Size - -------- ----:"--�.--------------'� <br /> I Water Supply: Public System and name----------- --------------- i �w: rvate , <br /> ! ...._.... . ----------- ----- <br /> - Character of soil to a depth of 3 feet: Sand E] Silt❑ 1a�.0 Peat E] Sandy Lobm Clay Loam 1, <br /> Hardpan ❑ Adabe�E] Fill NlateriaL_.- ---If yes, type..........�.__•-----........ <br /> ---- ` i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. mus be placed on reverse side.) <br /> NEW INSTALLATION: '(No 'septic tank or seepage-pit-perrraittad.i#-�ublic-se%ker is-available within 200 feet,) .1 , <br /> PACKAGE TREATMENT [ 1 SEPTIC TANK Size ___���_ -�.._.ol x_-�-__-•---------------- -------Liquid Depth_�z�__=______________ <br /> yp Material_ ` ..__._____No. Compartments._..._:•._._�__.__ <br /> Capacity/_o�,C a,'.__3T e_._-- -._........ . <br /> ' . Distance to nearest:.Well.:.=1 4 ._:-- ----- - ____Fa�ndation....�Q__�_..........Prop. Line.�� --------- <br /> It <br /> .. <br /> LEACHING LINE �t(( No, of tir�s_,.:-J� _.--:-----.Leng off jeach line d ��_ d --Total Len�th ......s Q------------------. <br /> A 4 `D' Box.__. _-_---Type Filter Material_.___-.RP_4_ _Depth Filter Material_,_/ ..--•.-.----------_--........ <br /> I. �---------------- <br /> i Distanceto nearest: <br /> I Nell. .46d-._._____ Foundotion-_-R.4------------------Proper'tyLine... .____--_ <br /> SEEPAGE <br /> PIT. [ ] Depth----------- ----Di amVter._. ._. ...Number...........::......________-__-__ Rock Filled Yes[] No❑ <br /> 4 1 Water Table`Depth = = -° ---Rock Size----------------------- ...... ............... . 1 <br /> Distance to nearest: Well-------------- ----------- <br /> fi---------- Foundation---------.----------------Prop. Line---------------------------- <br /> F <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------;-^.----- '-:-------_------------_:--.....Date-------------;-------- -- ------------------ <br /> ) <br /> Septic Tank {Specify Requirements)---- ------------------------------------------------------------I...........__,------==•--- -..---.--••----.-_---•-•-------------------------------...\ <br /> Disposal Field (Specify Requirements) --- ----- ------•- i.......................................-------------------------------------------------------------------- <br /> ------------------------------------- <br /> 1 1 <br /> l I (Draw existing and required addition on reverse side} ' <br /> I ' I hereby certify that I have prepared this application and that-the work will be done in accordance with Son'Joaquin County <br /> ' Ordinances,- State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home ownor or licensed agents <br /> signature certifies the following: <br /> `4 certify that In the perf6rmance of the work for which this permit is issued, I shall not employ any person in such manner as 1 <br /> to become .su ' to orkma ' Com nsation laws of California." <br /> F <br /> Signed-'------------- -+---- ------•_. ..... . Owner i <br /> ---- <br /> ir - r.. _ � - <br /> 8y= ...::.. = : .............Title -• ff�f . - <br /> t (If'other than owner) <br /> t <br /> FOR DEPARTMENT USE ONLY " t <br /> APPLICATION ACCEPTED eY___ _ _ _____ ._.___DATE.____/__A_ ................. <br /> DIVISION OF LAND NUM.BER. _ •--------------------- <br /> ---------------------------------- := DATE: : = ---- t <br /> ADDITIONALCOMMENTS----------------------------- ------------------------------------ ------=--------•---------- ------•------•--------------------- ----------------------------------l---- <br /> -- ------------------ - --------------------- . ----•-----. --•------ ------------------------------------------- ------------ ------ <br /> ------------------------------*.-----..........-------------------------------------------------------------------------------------------------------------------------- <br /> .__. <br /> Final.Inspection by:--_------------ - -•---". ._......... •--- ----"`. ...--"•-------...._.._..._. ._..Date......-- ---��--~ ---- ------------ . <br /> F . <br /> i EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&3 21677 Rev, 7176 3M <br />