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.I <br /> FOR OFFICE USE: A FOR OFFICE USE: <br /> APPLICATI(5,N'.�FORxSANITATION PERMIT <br /> ----- -------!'�l,J--- t� I� �; p Permit No. <br /> - <br /> \ ; (Complete inTriplicate) N <br /> ----------- -------------- -- -- - <br /> - Date Issued�,�- ".'==27 <br /> -_--------_-----____-"-----------------------I�_--------- <br /> This Permit Expires 1 Year From Date Issued <br /> ,F <br /> I <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 /> �. eCENSUS'TRACT_ -- <br /> JOB ADDRESSJOCATI <br /> Owner's Ncime-1--------- = ------- -------- :.: ---- e <br /> i 3 <br /> ..r <br /> - ----- -- - t ----- ---Zip <br /> MIL <br /> Address -- <br /> C <br /> co <br /> ntrabor's Name-- r� -- -- h ----- License #_ 7!_5. Phone <br /> �S �� <br /> Installation-wilI!Serve: Residence 4�Apartment House.ro Commercial ❑ Trailer 'Court ❑ 4 <br /> Motel E] ' Other- J --[---- � = ... <br /> Number of.living units:__ --- .;-Number,of bedra s--.- --_Gar Ige Grinder..J_-_- -Lot Size.-- �.' — -------------------- <br /> --�--` <br /> Water Supply: Public SysYem'ancl name---:.=----- = -------- <br /> Private ❑ <br /> Character of soil to a dept $ feet: Sand 0 Silt Ej. Clay F] Peat E] Sandy Loam E] Clay Loam ❑ f <br /> p , ? - yes, tYPe-------------------------------- <br /> or, <br /> Hd an. Adobe Fill N1trial_..__ ._ _ If e ' <br /> (Plot plan, showing size of lot, location of system in relaatio'n to-wells, buildings, etc. .musi be placed o} reverse side.) x <br /> NEW INSTALLATION: :(No eptic_.tank�or_seepage_pitj permitted if public sewer is available withi 200 feet,) <br /> PACKAGE TREATMENT [ ] i -SEPTIC TANK �tz ! ___'_-_- <'_______________Liquid Depth.________-_-- :-- <br /> I <br /> t _R4'� _T e .�P -_No. Compartments . - <br /> . . . Ca acit •-------------Material_-__ ----___-- <br /> Distance;to riearest: Well. _: 4 � - _____________Foundation_._ 4-----._....- -'-"Prop_ Line_.__-- <br /> LEACHING LINE: [ No:�of Lines_:_!__,___.-_- Length of <br /> !Aa line___ "S"-_ ___ .__.4._,Total Len,gtehi-_-- ________________ <br /> -. -- <br /> D' Box--:------ -Type Filter Materia l3P . ?�W-Depth Filter Matdrial-------/ <br /> i ---- <br /> Ye <br /> - <br /> ' Distance to nearest: Well ---Foundation- -J----------Foundation___�.L�____ __________.Propefty Line__--�_I__ <br /> Depth _ --.Diameter____ _ --------__ Number_._1_ _____--___- - ----- Rock Filled Yes No <br /> SEEPAGE PIT [ P - - ❑ <br /> I Water Table.Depthl. / = --------. -.Rock Size-- -------------------------------------------- r <br /> Distance to nearest.-,Well-------- f_�! --------- Foundation3::--/�. ---- ..Prop. Line___A0------------ --. <br /> REPAIR/ADDITION3 IM a + <br /> (Prev.,Sanitation Permit#-------------a_________________ <br /> --==--=----- - -.Date----------- --= =------------- � ------) <br /> SepticTank (Specify Requirements)--------------------------- _--------------------- ........................... -- ---------------------- ----------------------------- <br /> Dis.posal Field(Specify Requirements)----- -------------- - ------- ---------- ------ -------------- ---------------- -- - -.--------------------------------- ---- <br /> C = -----=------------------------ <br /> --- --- ---- - <br /> ------- ------- ----- ---- ---- ------- ------------ - <br /> i� --- ------- ----------=-- --------------------- -- <br /> ------- -------}------------------------ --- ------- - --------------- - <br /> (Draw existing and required addition on reverse side) ' <br /> I herebycertify that r have prepared this a lication and that the .work will be donei in accordance with San Joaquin County <br /> Y P p pp � ' <br /> Ordinances, State Laws, and Rules and Regulations of the Sari Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the perfo mcTnce of the work for which this permit�is issued,1 shall of employ any person in such manner as <br /> to become s ct o Workm 's. Co pensation- laws of California." - <br /> Signed------- ;4. : ;Owner <br /> - <br /> i� { <br /> ---- <br /> ------------------- i - -------------------------------------------------- <br /> By <br /> (If other than o T ` <br /> tle s_._ <br /> FOR DEPARTMENT'USE ONLY I <br /> APPLICATION ACCEPTED =-------------.-------------------------- DATE. . 7! <br /> DIVISIONOF LAND NUMBER --------------------------------------- ---------------------------------------------- :------------------------DATE-•------- ----- ---- --------------------- - <br /> ADDITIONALCOMMENTS-1----------- ------------------------------------------- -------------------- ----------------------------- ------------ ------ --------------- <br /> ------------------I-------- -------- -------------I--------------- ------- ------------------- ----------------------:�_w-------------------- --------------------------------:------ <br /> I <br /> ----- :--- <br /> IIM ---------------- -----------------------------" <br /> -------- - ----- ------------------------------------------ ----------------------------- <br /> ----- - ----------------- ------------------------------------------------------------------------------ --- --'---- --------- ---------- <br /> P Y p ., ------- ------- Date_:,2, s -� <br /> - --- --------- <br /> I <br /> Final Inspection b <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT y F&S 21677 REV. 7 <br />