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FOR OFFICE USE: FOR OFFICE USE: <br /> =� APPLICATION FOR SANITATION PERMIT G <br /> = -� _ <br /> f <br /> ------------------------------------------ Permit N6.. - <br /> (Complete in Triplicate) --�----- -- <br /> --------------------------- ------ <br /> 1 Date Issue <br /> a ----.----------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for 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 /> f <br /> JOB ADDRESS/LOCATION. _- :�� -- #�`._ :--.; ""- CENSUS TRACT--------------------------- <br /> --- r <br /> Owner's Name._/ -- - ----- _-------------------------- one--------------------------------------- <br /> Address <br /> -- ----------- <br /> Address �1. % x� -fig•- -- -- - ----- -- -'---- L� - '� '-^a <br /> City �; Zip. <br /> r <br /> Contractor's Name.----- ,?41A <br /> =-----;-- --_-------- ------------- ---- --- - License '#_ _3 :--Phone_'zZ ���-------------- <br /> Installation <br /> � - <br /> Installation will-serve: ' kesidence` ❑ tial ❑ ,r ❑ <br /> ;Trailer Court <br /> t Apartment House Commercial _ <br /> ?.. Motel ❑ --..Other- i <br /> ----------------------------- <br /> Number <br /> -- -- ---------- i" <br /> �/ r 1 <br /> ------ <br /> Water Suof II`!`Pub!cts: st�-•-n Number of bedrooms:..--Garbe a Grinder..____. Lot Size------•---i._--------- ----�-r`�--,,;--- '--- i <br /> I g - <br /> /�] g <br /> pp Y: y a d name 1 - Private ❑ <br /> Character of soil to a de•th of 3 feet: Sand Silt Clay Peat Sandy Loam Ej Clay Loam ❑ , <br /> - <br /> Hardpan ❑f Adobe; '.Fill Material-..---------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.) i <br /> NEW INSTALLATION: (No.septic tankor-s'eepa-ge pit permitted if public sewer is available within 200 feet,j - <br /> PACKAGE-TREATMENT r .�. S� -- Liquid Depth--------------------------tT <br /> ["]"', 5EPTICTANK '', Si�ze x___ <br /> r' Capacity `:[?f_d�--"`Type - :-- _ Material: - 'c -__-:- -No.•Compartments--= ---:__�--:----------� - <br /> # - - r I <br /> _... tDistance;to nearest: Well_;-- -- -C% <br /> '.--.,__. FFoundation._�D---.---- - ---Prop. Line,_-------------- k <br /> LEACHING LINE jj No, of Lines- - --- -------------- of each line... _,.,_ ----------------- I g ----- <br /> 1Total Len th1 <br /> pth Filter Maferaal -- ----------------------------------------- <br /> DI < <br /> Distance to nearest: Well__._ _ _ -____.Found <br /> ' Box Type Filter Material __ __ _ De <br /> ation - Property Line---------------------------------- <br /> --------------- <br /> --�-------- - ------`---- <br /> !S <br /> SEEPAGE PIT <br /> Depth--' <br /> epth_ _sem _.....----Number---'._ 3 Rock Filled Yes. No <br /> Water Ta61e.Depth- -- -----/----- - Rock Size1 '1.__X3 - --- - - <br /> Distance to nearest: Well :_--:--:_: u <br /> Fo ndation__* -_-.Prop. Line--- ` <br /> REPAIR/ADDITION (Prev. Sanitation Permit# ....----------------------- `:__:='-:_- ,.Date------=----- -----:--'-:-p____------_--•-_-- <br /> -. <br /> SepticTank (Specify Requirements)--------- ----------.-------------------- ---------------------_------=----- -------- ------" =------------.-=----------•-:---- --- ; <br /> Disposal Field (Specify Requirements) s -- - ------------- -- '------------------------ -------------------------- <br /> --------------------------------------------- <br /> 7 f <br /> ---- <br /> ---_---------------------------------------------------- ---------------------------- - _ _ __------_------_-____ _..-____..__.__..________ .. <br /> (Draw existing and required add ition:on'reverse_side) 1 <br /> I hereby certify that I have prepared this application and-that.the work-will=be-donen accordance with -Sam 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 following: <br /> "I certify that in the performance of the work for which this-permit is issued, 1 shall not employ`any ' ion in such manner as i <br /> Signed___.___m6-to � aCampensation: lawsCalifornia." <br /> �of Caf -. . . <br /> o <br /> to ecome ect to Wor man b � � } � <br /> i <br /> -------- <br /> By-1 <br /> ------ <br /> ) <br /> OT <br /> iWeer J (t <br /> BY � f - - , - ---------°-- -------------------------- <br /> --------------------------------- - <br /> n' w( fBothetii : f <br /> i . .......... FODEPARTMENT_USE ONLY <br /> All <br /> APPLICATION ACCEPTED BY------- - 11a ._:.._ DATE:--'---'-- -- -- -- ------------ - <br /> -- ----- --- - <br /> DIVISION OF LAND NUMBER._ _ -- -----------------__ r - DAT/E <br /> - ----- <br /> �ADDITIONAL COMMENTS......... <br /> t <br /> .,----------------------------- �.,...,�__ _ .....� r <br /> --------- --- ----------------- ------------- -------------------------------- <br /> ------------------------------------------------------- ----------------------- ---------------------------------------------------- - ------' - ------------' --- ------- ------------ <br /> ----- ------------------------- ------------- ----- -Yl Inspection <br /> . . r.Fina -- - ---- -- - ----._., <br /> ------------ _Date___ <br /> EH 13 24 S JOAQUIN LOCAL HEALTH DISTRICT res 216n REV. 7/76 srn <br />