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rVK UrFlU USE; <br /> .......... .............;--Z............................. APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit NJ, <br /> ...-11.11-11.11................... <br /> .............. <br /> ...................................... This Permit Expires I .Year From Date Issued j <br /> Date.Issued ........... <br /> Application is he'reby made to the San Joaquin Local Health District for a permit to existing <br /> install the work herein <br /> described. This application Is made in compli �nci`,'With Count�,' Ordi nce N ' <br /> DO 0. 549 and..existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO .... .......... <br /> ............ CENSUS TRACT <br /> ---- ------- ....... ............ ... <br /> Owner's Name ........... ....... <br /> .. <br /> ------ ...... .. . . ......................................Phone <br /> Address ......... <br /> _9;�Jt. ............. . . ........F,571" <br /> Contractor's Name 7 ---- -- ......... <br /> 4— P <br /> ...............License 0 hone <br /> Installation will serve: Residence 0 1 <br /> Apartrnent.HouselLi m rcial C)Traller Court 0 <br /> Motel[]Other L. ..... <br /> Number of living units:...........: Number of bedrooms .:..........Gbrbage Grinder .... ....... Lot SIZ4. ........ <br /> Water Supply. Public System and name , <br /> .....I............. ................Private 0 <br /> Character of soil to'a depth of 3 feet: Sand Silt[] Clay. 0 peat. Sandy Loom,0 \ - <br /> Clay Loom 0 <br /> Hardpan 0 Adobeo Fill Material'........... if yes,type.................I......... <br /> t"n <br /> 5�04t Plan, showing"size oVIot, location of sYstemAn relation 4o wells, bouilding <br /> . t. '*t S, etc.'must be placed <br /> I 4 . - t ;ed on reverse sidi.) <br /> NEW STALLATION' :. e I <br /> (No s Ptictank'or seepage pit permitted if public sewer Is available within 200 feetj <br /> I IC <br /> PACKAGE-TREATMENT' I EPTICTANK f.] sl 6 <br /> ze................... ................ <br /> Liquid Depth .......................... <br /> Capacity J...... ... Typ. .......... Material........._ <br /> e 1. 1 <br /> 7 1 1 --k �%�4- . ............ No. Compartments .................. <br /> Distance to nearest, Well I <br /> ....................................FWpVndat1on_..1.;t�....... <br /> Prop. Line ........................ <br /> LEACHING LINE No.lof-LinesL-ength-of-.!Dach line........... P4 1 E <br /> Length4........................... <br /> D* Box .... Ty I <br /> Type filter Material .....................Depth Filter Material ........1. .1 <br /> . ............... ................ <br /> -Distance to nearest: Well I I <br /> ''Foundationi ..... .................. <br /> D Pth ........................ Prop"i Line ..... .................. . <br /> SEEPAGE PIT j ) ' 4, i G <br /> ...... ............. Diameter ................ Number .- Rock Filled Yes [3 No <br /> ater <br /> Table Depth ... . ..................... ...R <br /> 9t ck Size. .... 1�Distance-to- earesh-Wel - . .........A.. <br /> .......................0 <br /> ................Foundation .. Prop. <br /> . Line .REPAIR/ADDITION(Prev. Sanitation Permit# ...... ....... .................... <br /> . ........ .....I........... <br /> Septic Tank (_Speli <br /> fy Requicdrenti ... . <br /> -------- .... <br /> ............... .. . I . ...................... <br /> Disposal Field JSpecl4j -Requirem'entsi ...... <br /> ................. <br /> . . . ......... ........ <br /> ....................... V-:p�X � . . '0 LA ....... ...... ------------- <br /> ...........................................f - <br /> I _ f --__­ ..... ...2 �.. . j ..1........... ....... <br /> ........... .........r..........I ........I..................... <br /> ..................................... ............. ..............I I <br /> .....................A......................................... ............... <br /> (Draw existing and required addition onreveise side) I <br /> I hereby certify"th-dih,shave prepared-this and that thework will be done' In accordance with Son Je ufn <br /> County Orilinantes,[Sta`1e,1 aq <br /> I Laws, and Rules and Regulations of tho' Son Joahuln LocalllNeWth District. Home owner or llceti <br /> seidoqen a " *.�0—f 1� �1 <br /> ilOhature c 5 Gj allowing. <br /> V <br /> "I certify thait in thelp 0 '4 <br /> cis to becom " I I . nce of,the work'for which this permit Is Issued, I shaft n-p-t-*rnploy any person •In suciii manner <br /> 0 subiect to-Workman's Compensation laws of California.- <br /> Signed ............ <br /> .. ...... ..... ...... ................................ Owner <br /> er ti th <br /> arf a <br /> By ...... <br /> ......... ------- ........ <br /> .......... ............. TitleIf ..........5�*A` <br /> othern owner) ....... .............. ........ ........... ....... <br /> FOR DEPARTMENT ;USE ONLY <br /> 7F <br /> APPLICATION ACCEPTED BY ...........�.i Or <br /> BUILDING PERMIT ISSUED .'—......... .... ...........lr....................................... DATE .... ........... <br /> COMMENTS <br /> . ........ <br /> ADDITIONAL COAWENTS ... -,oK- -------------- .................. ...DATE ....................... ........... <br /> ................... . . . ........ ....*....... ..........W.4......... ................................................... ................... <br /> .............. <br /> ...........I........................I................ .................. .............................. ............. <br /> ..............._..--•-•-....--•--... .i_. <br /> ... ... ............................ ................... ......... <br /> ...... ......... ....................... <br /> .......... <br /> ................... ;��...... ........................................................I............................ <br /> Final Inspection by: ------ <br /> .•........... ....................... ........ ...... Date <br /> ..... ......... <br /> ...... ...........6.....Date ./Z ........... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />