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FOR OFFICE USE: FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------- ----------------- 7f-lf� <br /> (Complete in Triplicate) Permit No•................... <br /> This Permit Expires 1 Year From Date Issued bate issued...__-_5_ <br /> Application is hereby made 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 /> 47 <br /> JOB ADDR55/LOCAT]QN.,w ,__� } <br /> Owner's N�me-------- <br /> F .. hone_ 3_ <br /> Address ... .!� f -- Crty�� {I ''� ZiP <br /> Contractor's Name } -�- -'LicensePhone. ....S'�l <br /> = ---- _ <br /> esid <br /> Installation will serve: Rence ) Apartment House.❑ Commercial ❑ Trailer Court ❑ ' <br /> k - Motel , <br /> ❑ Oilier ---------- ---- --- - --- --- �.. � <br /> t. . <br /> Number-of iving units:....-- _-__-__Number.of bedrooms ._..Gar age Grin er ___.: of Size___ <br /> I. PI?y: Public Syste nd name----= j ,_ = ...�� t!�`'� ~a �. Private <br /> Water Su t P _ _ <br /> Character of soil to a depth of 3 feet; Sahel ❑ :Silt❑ flay ❑ Peat❑ Sandy Loam " Gad Loam ❑ + <br /> Hardpan ❑ Adobe ❑ Fi I Material .._.If yes;type. `-__ '_- - ' <br /> r <br /> [Plot plan, slhowing size of lot, location of system in relatior,jo:wells, buildings, etc. must be placed on reverse sid .} <br /> NEW INSTALLATION: ' (No septic tank'or seepage p�yitsperm'tYed 'f public sewer is available within 200 feet,] <br /> J'i✓t <br /> PACKAGE T EATMENT [ ] .`SEPTIC TANK-,[,] Size------------------- <br /> ------Liquid Depth_____ <br /> a - - - ------ <br /> Ca dcit Type.-...­_:--------- ---Matwial = - No Compartments- ----- F <br /> ! { ------Foundation _ . ------- - <br /> [! __.F ....Distance to nearest: Well. 4 Pro Lm <br /> LEACHING LINE.. [•] No. of Lines-:------ ------- Length of each line---.-.--,- _ -.----Total Length.------------- <br /> .'D' <br /> _D' Box--- -_Type FilteriMaterial----_ -_----. Depth,Filter Material------------------------------.--__ . ----------------- <br /> - 1 . <br /> r \ r. I . ._,. <br /> Distance to nearest: Well].......:...................Foundation----------------- _--._ '..-.Property Line_._ __________---- <br /> SEEPAGE <br /> --- <br /> SEEPAGE PIT [ ] Depth--- Diameterl- - . ------ ---------------==--- ' R ill N <br /> ._ p --- ---------------- ---- 1�5�� --- .I -�°. � ock F' ed� Yes ❑ o ' <br /> ... �um er.-�' --.Rock <br /> Water Table De th--------- -_ t <br /> i - -------------------- ------ Y <br /> # Distance.to nearest:Well----------------- ------ --- - [--- -Fou#dation --------u- = Prop. line <br /> I <br /> REPAIR/A <br /> D ITION [Prev. Sanitation Permit#_`-. ._ ----- ---.- --------------------- <br /> Septic Tan --- <br /> Sep <br /> Tank Requirements)---.------- '- <br /> I k <br /> r = <br /> Disposdl Field (Specify Requirements)-------- ..._}-..._ _ <br /> ----- ------ ------• ----------------------------------------- <br /> `t. <br /> __..- -___.. - t i <br /> �1 51 - ----..------------------- -----"--_ -----.__ ____ Y ._. ____. --- __-__-.-..--._.___ <br /> i s prwW e'xist,ng and fequi e—d arc clition on reverse side)': . •� i` <br /> hereby.ce ify that I have prepcsred'this.application and that.the work will be -done-in Qcordance with San ijoaquin"County� � � <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Healthistrict, Home owner or licensed agents <br /> signature ce ifies the following: <br /> "I certify'thlit in the performance of the work for which this permit is issued, I Shog of emplay�any person in such manner as <br /> to become l6ubject rkman's Compensation[ lawsof. .California," <br /> ! ti rJ } <br /> SignedtT-- - ' ' w -\ --Oner h <br /> 3!' <br /> B f <br /> -- ��---- -- � � - ---- - Title------.-�-- ------------- <br /> (If <br /> --------(If other than owner) % r'} � <br /> " OR RT DEPA64 ttIJSE NLY: <br /> APPLICATI ACCEPTED By--------- -------------- ------------------- DATE- 3 �� <br /> DIVISION OIF LAND NUMBER...--- ' ------- --- ---------- <br /> - -------------------- <br /> T - ------ <br /> WADDITIONAL COMMEN =' - <br /> --------- --------------------------- <br /> ------------ -. E <br /> ---- " <br /> ------------ <br /> Final Inspection by: --- ----- --------------------------------------------------------------- Date <br /> EH 13 24 SAN J QUIN LOCAL HEALTH DISTRICT Fes 21677 R v 6 3M <br />