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FOR OFFICE USE: FOR OFFICE USE: <br /> �. <br /> APPLICATION, FOR-SANITATION PERMIT 7 ,�;1�4 <br /> _ Permit No----- ------------- <br /> ------------- ! (Complete in Triplicate) <br /> ' a 6_(1. Date Issued-------- ------ <br /> _ is Permit Expires 1 Year From Date Issued <br /> Application is hereby ma a to the San Joaquin Local Health District for a 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 /> JOB ADDRESS/LOCATION+---- �_ �. - ___ -- r-- - CENSUS TRACT__________________________ <br /> Owner's NameC�i r,�, rt =------ -----= ------------------Phone--- --------- .----- --------------- <br /> Owner's Name <br /> ------------------- <br /> Phone-Iry <br /> ?/.. - City.- ZAP l <br /> �. }... -- <br /> Contractor's Name t � ( `------ ------- License #_ ----- Phone _ <br /> d <br /> Installation will serve: Residence ❑ Apartment House.(] Commercial ❑ Trailer.Court El <br /> e.._.M�-... �..W Motel ❑ Other-----------I------------- -----------=- ----- a r <br /> f �� 1 --------- ------- <br /> Number of living units:-.---_..l-___ __-Number of bedrooms'__._______-Garbage Grinder --___.-___Lot Size__.. <br /> Water Supply: Public System and name--------------------------------------------------------- _------------------------- _ Private <br /> I <br /> 41,-k- "I.� } " . <br /> Character of soil to a de�th of 3 feet: :Sand ❑ Silt❑ Clay ❑ " Peat ❑ Sandy Loam ❑ .Clay Loam , <br /> p <br /> Hardpan( Adobe` Fill Material _If yes, type.___ <br /> — <br /> (Plot plan, showing size of lot, location of system in'relation to•wells, buildings,etc, must be placed on reves�eside.) <br /> NEW INSTALLATION:' (No septic tank-or seepage pit pe itted f public f wer is available within 200 feet;} C�� C <br /> r :.. <br /> Size k/ Liquid Depth �r ..........-; <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ( / �-- ---- <br /> t , <br /> ' No. Compartments._.__ <br /> ' t --T a Matarral _�- - - ' <br /> CapacitY. ���p� Yp � <br /> r *ten �j r '1` ' Pr 'e. rte_`-- �� k <br /> [ Distance.to nearest:.Well - --_1 ---- ----------------Foundatio -- Le •-Prop. Lin (� ` <br /> No. of Lines_'.__-- :Length of eachline.__,_�. _ ___-^` s.Tatal"LengFi ._�. 4 _ --. <br /> LEACHING LINE: , ::.:_: g ,, <br /> r ;D' Box---------- T e,Filter.M"ateriaL__ 1_ De th Filter-Material ' _ <br /> 1 j �Y.P •+_.,, ; . p _fir { r k r ` . <br /> :Distanceto n crest: Well f� - - ----- <br /> - Fou` ' <br /> SEEPAGE PIT De th.. Diameter_:. ' Number �` - s <br /> Fr1 <br /> �/� Rock led�Yes� Not❑ <br /> t Y <br /> 4 Water Table'Depth__ = <br /> Rock {r <br /> i t Lr - <br /> - • . . -Foundation. �a -- - - Prop. •ne.-- -- ---- ------ <br /> Distance to nearest;Well.-=-_-__.�+�--:---------'------- - <br /> i , i <br /> REPAIR/ADDITION (Prew-Sanitation Permit#_- pate = ..:._.... f <br /> Septic Tank (Specify-Requi-rements)�-- ---- = _ __--��------- • ------------- <br /> '.i .-- <br /> - _ � ' <br /> Disposal Field (specify Requireme s ____ ._ � - ------- <br /> -----=------------------------- ----------- -------- --------- <br /> -----•--------------------------- <br /> ( - - ---- --------------------------------- <br /> ---D t � ' <br /> - - - - ; <br /> ( raw ezis frig .an required addition on reverse side) <br /> 1 hereby-certify that I have-prepared this-application-and that the work will be done in. accordance with San Joaquin County <br /> Ordinances,_State-•Laws, and--R'kes-and•-Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the follbwing` <br /> "I certify that in the performance of-the.�yk for w hick-this permit is, issued, I'shall not employ any person in such manner as <br /> to become,-,�subject-to-Workman's Compensation laws of_ California.'..' <br /> . ; t <br /> • Owne <br /> Slgned_ <br /> I - --- ----------- -- ------ ---- - <br /> BY- ----- ----. <br /> c ----------------- : Title <br /> (If'other than owner} <br /> ( Al FOR`DEPARTMENT USE-ONLY <br /> .. . ..,. <br /> ;. --- ---------- --------------- <br /> APPLICATION ACCEPTED BY'------� ------ --------------------- -.--------- DATE if <br /> - - --- ----------- -------- - <br /> DIVISION OF LAND NUMBER-------- -- ------------- '- -----------s...--` '------'------ .::-- .---. -- --------- _DATE. <br /> - <br /> r. ....s- <br /> ADDITIONAL COMMENTS ` ' ----------------------------------------- <br /> ' l .. - ---------------------- ---------- ------------ - --------------------------------------- <br /> ----- -------- --- ------- <br /> F <br /> I -----------------I----------- ------- --.--- -------------------------------------- --------- ---------------- ---------------------- <br /> ------------------------------- <br /> $ <br /> ------- ------------ <br /> I r - ---------- ----------------- -------------------- ----- -- ---- <br /> -- <br /> ---- --------------- ------- <br /> Date,:ae <br /> Final- Inspection ------------- ------- ------------ ''_ •- »63N <br /> I <br /> FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV.7 <br />