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FOR OFFICE USE: t:.A a. 'Q Loci-- � <br /> APPLICATION FOR SANITATION Loci-- PERMIT 617 ,� <br /> Na-- ------------- <br /> D -- t rv,N� Permit,,,. ,_ti-.., _... <br /> !_.......@ (Coni `lete-iiii Tri-licarte) ".....`..� t <br /> s• 7 . <br /> ____ _____________________________ <br /> 1 Date Issued&`-3d-7.--. <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein d <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ` <br /> 1 <br /> ._CENSUS TRACT <br /> JOB .ADDRESS/LOCATION ._- _ ---- --1-- <br /> ---------- -_Phone�-------- ------------•-- -------•- <br /> OwAr's Name - e-�----- �o 4Z'------- --------- ----- f i <br /> .� f city , ------------------ - ••..-- <br /> �' '�' <br /> Address ��s��.-/��y----'--j-4 <br /> Contlactor's Name - l�/d •-! p -------------------------- -- License # Phone <br /> Installation will serve: Residence�artment House E] Commercial :[]Trailer Court ❑ <br /> Motel ❑ Other -------------------------------------------- . f <br /> /� �__.-_Garbage Grinder - Lot Size X40140--X-- ......... <br /> Number of living units:--/----- Number of bedrooms . <br /> water Supply: Public System and name _ ------V--la,+0 ----------- --------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam 'E] Clay Loam <br /> Hardpan ❑ Adobe�g Fill Materiat ------------ If yes, type---------------------------- <br /> (Plot plan, showing-size of lot, location of system in relation to wells, buildings, etcmust be placed on reverse.side.) <br /> NEW INSTALLATION: (No septic flank or seepage pit permitted if Rublic�sewer is available within 200 feet,} ( � <br /> SEPTIC TANK +----•------ Liquid Depth711 <br /> = =---=--== <br /> PACKAGE TREATMENT [ ] .��, ( � <br /> "` -_ Material No. Compartments ---------•-"--- -_••-• W <br /> Capacity/�� ------ TYp�� -- - � . <br /> -ter- Prop. Line ---A -- <br /> Foundation _ JJ <br /> Distance to nearest: Wel[ ---------------------------- ------- F ------------- - <br /> i <br /> i LEACHING LINE No. of Lines __-- _ Length of each line ___ ------------- Total Lenges - ---- <br /> 'D' Box - Type Filter Material ;�Oe�WDepth Filter Material l ------------------------- <br /> Distance to nearest: Well -_ "'---- -- Foundation -- 0------------- Property Line -- ---•=-•-• <br /> x e <br /> i ''r �No <br /> ,, Number ___.--�-___-------,�r-- Rock Filled Yes <br /> SEEP, GE PIT Depth _v4_ _------ Diameter <br /> � Rock Size!"` <br /> t Water'Table Depth �____ -------------- -- <br /> -�—�� Foundation --- � ProIf <br /> Line ---�----....... <br /> Distance to nearest: Well -------------------------------------- ------ p' <br /> REPAIR/ADDITION(Prev. Sanitation.Permit # -------------------------------------------- Date .-----_-.---------.... --------1 # <br /> Septic Tank {Specify Requirements) ---------- -------------------------------------------------------- f <br /> L Disposal Field (Specify Requirements) --- -- "___ <br /> ----------------------------------------------------------------------------I----------- <br /> ------------------------------------------- <br /> ---------------------------------------------------- i------------------------------------ --------- <br /> {Or g ------------- --------------------------------------------- •---- <br /> -------=-- ----------- ----------- --------- ---------------------------------------------------------------------------erse side) <br /> &.. existing and required addition o <br /> 'w [ hereby certify that f have prepared t i� application and that the work wEl be done in accordance with San lquin <br /> Cou ty Ordinances, State Laws, and Ryles and Regulations of the San Joaquin Local Health District. Home owner or; licen- <br /> sed agents signature certifies the following: ft <br /> "I ce tify that In the performance of the work fo 'wHpct this,perm� is issue ; I a not emp oy any person in such manner <br /> as to� ecome subject to Workman's Co pen ion laws rNalifornia." <br /> Signed -------------------- Owner <br /> 10 <br /> ------------------------- Title --f3'��' ------------------------------ <br /> By (if o an owner) <br /> F ENT USE ONLY '4DEI'. <br /> E �_ <br /> --------------------------- ---------------- <br /> DATE - ---------------------- ---------------- <br /> _ APPLICATION ACCEPTED BY ------ ---------- - DAE ______-______•--- ---I <br /> �---- -f------------------------------------------------ <br /> ------- ------ - - -^- --------------i�.�..w-::w ---------------------------------- ---------- <br /> BUILDING PERMIT ISSUED -------- -------- <br /> ------- =1------------------------------------------ __- <br /> � ADDIONAL COMMENTS �-- - -- ----- ' <br /> 9� <br /> ------------------------------------------------------ --- <br /> +� Y� ------ - r <br /> - - Date __ -- <br /> i Final Inspection by: _ ----`� ---- ------ - <br /> SAN JOAQUIN LOCAL $HEALTH DISTRICT <br /> - .�.,,�'f" zs! Rev. 5M. - <br />