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_-i-FOR OFFICE USE. <br /> -, R OFFICE USE, <br /> f�o 1/,.-v IJ3)— <br /> . . . ... ........ <br /> ------ ---------- APPLICATION <br /> ----------------------------- FOR N, <br /> R SANITATION PERMIT <br /> - --- - ------------------- ---------- ------- (complete in Triplicate) Permit 0, <br /> --------------------------- N <br /> ------------ -------- <br /> - ------------------------------- This Permit Expires I Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct aro install the work herein <br /> described. This application. is made In compliance with County Ordinance, No. 549 nd <br /> exisfin Jules and Regulations. <br /> JOB ADDRESS/LOCAJI.ON&;?,*7 <br /> Owner's Name t9 _!50 _P _J a f <br /> 0 <br /> _._ _ <br /> _4 A( � __X - --- ----------C SUS TRACT <br /> Address ------------------------------------- <br /> ---- -- ------ ---Phone -------- <br /> Contractor's <br /> --Phone.- <br /> Contractor's Name W---------------------------------- City -------------------------------- <br /> ------------- <br /> ------------License Phone� <br /> Installation will serve: Residence <br /> kpartment HouseED Commercial oTrailer Court <br /> Motel 0 Other 0 <br /> Number of living units.----.4--- Number of bedrooms -..?__-_Garbage Grinder o W- Z?- Lot Size t <br /> Water Supply: Public Syste � and name ................ <br /> M <br /> Character of soil ----------------------------------------------------------------- <br /> to a depth of 3 feet, ScintEl Silt.o. Clay . ---------------Private;K <br /> Peat 0 . Sandy Loam <br /> ;K. Clay,Loam F1 <br /> Hardpan El Adobe El Fill M'aterial <br /> ------ If yes, type---------------- <br /> ........... <br /> (Plot plan, showing size of"lot, location of system <br /> I in relation to wells, buildings, etc. <br /> NEW INSTALLATION - :t must be Placed on reverse side.)M� (No,septic tank or seepage Pit permitted if Public sewer is available within 200 feet,)PACKAGE TREATMENT f I SEPTIC TANK 0 .4 �A I <br /> Size--3/X-9 _9_4�---- <br /> --- ---- --------- Liquid Depth <br /> ---- Typel ------ <br /> Capacity f, ------ <br /> MaterialCV-10�- e-tfw No. Compartments <br /> Distance to nearest: Well <br /> ---------------Foundation "o 7------------- Prop. Line <br /> LEACHING LINE No. :�f Lines <br /> Length of each line--PO--- ----------- --- Total Length <br /> 'D' Box 12. <br /> -::F- Type Filter Materia pth Filter Material <br /> -to nearest.. Well le <br /> �­_ —" 0 ft- ----------- -------------------_- <br /> Distance V/76414t I De <br /> SEEPAGE PIT -------- fZ­uri8afli6'n:-/J�1- <br /> Depth ------2��Property:Line.-' <br /> Diameter ---------------- Number <br /> Water" Table Depth ---------------------------------------;........Ro-ck-Siz-e Rock Filled Yes No [] <br /> Distance to nearest.. Well ................. <br /> 11 ...........Foundation -------------------- Prop. Line ---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---- <br /> - _----- .................................... ............ <br /> ements) ---- ---- <br /> Septic Tank (Specify Requir' Date _____________________ ; <br /> Field (Specify Requirements) ---------------------------1--------------------------- <br /> ----------------------- ----------------------------------------------- ------------------------------------------------------------------------------------------------------------------- <br /> -------- ----------------------------- , - -.w- _i_, .. ------ ---------------------------------------7---------------------------I <br /> ------------------------------------------------ <br /> - --------------------------------M!--------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulati6ns of the Son Joaquin Local Health District. <br /> sed agents signature certifies the following: Home owner or liven- <br /> sed <br /> certify that in the performance of the work for,,which this permit is <br /> as to become subject to Workmissued, I shall not employ any person in such manner <br /> " e <br /> Signed -------- --- On's Compensation laws of California.- <br /> ------------- - - <br /> 4��4------ ---------- Owner <br /> By ------------------- ---- d., ; ------------------------- <br /> -- - - -------- ------------------------------------------ -Title ---- <br /> ot er than owner) —---------------------------------------- <br /> FORDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> BUILDING PERMIT ISSUED --------- ------------ --------------- DATE <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------- ---------------------------------DATE ---- - ------------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------I----------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- <br /> ---------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------Final Inspection by- --------------------- -- <br /> ----------------- <br /> --------------------------------------------------------------- <br /> --- <br /> - Date /1�_---_--9- <br /> ---V- <br /> ------------------------ <br /> SAN JOAQUIN LOCW"fEALTH DISTRICT <br /> ,�8 Rev. 5M. A <br /> , <br />