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rvrc arEc:e vet:: APPLICATION ICOR SANITATION PERMIT <br /> ., . (Complete In Triplicate) Permit No. <br /> . . . . .. .......... ..........�, ..�: ... ,a„�„r This Pe"nit Explres ! Year Irom bate'Issued w� Datb"laaued <br /> Application is hereby evade to the San Joaquin Local Health.D.Istr1crfor°.a..permit to o butt'and-install the work herein <br /> described. This-applicati-on isinade'ln c6mpiitiao,with irounty_Orclinan_ci`,No. 549 and existing Rules anil'Regutotlons, <br /> JOB ADDRESS/LOCATION .Z7:7A9.. ..-- T CENSUS TRACT ......... ' # <br /> Owners Name . .j................................ r ............Phone der.' 3...:..�.��..; <br /> Address :12a.........................City j <br /> Contractor's Name ..:l. .•-•••-•......................................License# . . .. rid., Phone .93j;�4:.�,��426 <br /> Installation will server a dents artment House Commercial n <br /> ` ❑ ❑Trailer Court ❑ <br /> Motel ❑Other....... ..............:..................... <br /> Number of living units:.....:......: Number of bedrooms ._?.....Garbage Grinder. -------------Lot Size _ ''.--•...........................: <br /> Water Supply: Public System acid name ................... <br /> 1 ......_....__ ._. ... ......._............................................Private I <br /> i <br /> Character of soil to a depth of 3 feet: Sand❑.. Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loarn 0 <br /> Hardpan❑ AdobeA F€11 Material ............If yea,type............... ............ <br /> V�l <br /> 4 i <br /> $Plot plan$ showing size of lot, location of'system In relation to wells, buildings, etc. must be placed an reverse aide.) <br /> NEW INSTALLATION: (No septic tank or.seepoge pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENTSEPTIC"TANK( S#ze......:......................................... Liquid Depth ........_...............Capadtylype • ------••--- - Material......._..--•---...... No. Compartments 2q' .......I <br /> . E <br /> Distance to nearest: ................Foundation .v! r lQ t ; j <br /> Well ..... . D ... $�.._.......... Prop. Line . . ............... [ <br /> LEACHING LINE <br /> o. of Lines .-.. _.._ S' <br /> ft�/N --- - Length of each line.....-•-•--•.-.�...........Tota! length Y2461W......�... <br /> 'D' Box -.----.----- Type Filter Material . . <br /> ...Depth Filter Material ............................ <br /> I <br /> Distance to nearesto Well ........................ Foundation ........................ Property Line ....................... <br /> SEEPAGE PIT Depth ... _5....... Diameter ' .�....:. Number ......s ...:................ <br /> .....�_ Rock Filled YesV No <br /> - -= -� - <br /> Water Table .Depth - ...4..._........................:....: :Rock Size 42 R <br /> !Distance to nearest: Well '. ...............................:Foundation ........_. ro . licca .......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..........................................pate ..................................I <br /> Septic Tank (Specify Req irements) ......... .........................................:._'.._...-------.._................................ � <br /> Disposal Field !Specify l Requirements)"' N � ° '- -»r- — - - .... <br /> - '.I 1 ........... .. - .......-•----....._...................------. ' . <br /> .......................... t '-`` �. <br /> -- ...........................`-----•--....... ...._.........•... <br /> (Drawxistir g,and required addMo&'on.reve.r.s. <br /> everse tilde} ...................................... <br /> I hereby certify that I have,prepared this;amp list!a d that the work�rnr11"one In accordance with San Joaquin i <br /> County Ordinances, State laws, and Rude: and Regulations of the San':Ioaquin Local Health District.Hoene owner at Ilcen- <br /> sed agents signature certifies the following: <br /> 401 certify that in the performance of the work for which.this permit Is Is`4&d0 I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed1,914-4 <br /> � s ,. ' <br /> �/ 4. • .. Owner <br /> By .............................................. .-.-�.♦ Title <br /> (if other than ow .... _ ............. <br /> FOR DEPARTMENT use ONLY ° <br /> APPLICATION.ACCEPTED-BY....... .......... ................. DATE . .1 ..7 .:............-'.= <br /> BUILDING PERMIT ISSUED -.-: -. <br /> ....................•-..............._.....-•---..........----•........._...._.__.............---------•..DATE .... ..................................:... <br /> ADDITIONAL COMMENTS ................... ....:...... :.....:.._.... <br /> ..............................................:.........�-----•--................ .......... ...................---•----••- <br /> _............................. <br /> .. ..�.. 7....__......... <br /> Final Inspection by '!? ' ......................... ©ate ! ... c �.-7. z.... i <br /> ............ ...................•----- <br /> Eli 13 4 1-60 Rt V� 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 5/7h 3M 1 <br /> 1 E <br /> 1 <br />