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FOR OFFICE USE: - <br /> r' APPLICATIONa � FOR nANITATION PERMIT <br /> I' ---:- ------------------------------------------------- Hermit No= _7_Z-_S_�3 <br /> �n p Triplicate] <br /> f` This Permit Expires 1 Year From Date Issued pate Issued - <br /> Application is hereby made to the Z_J_0acfuin Local Health District-for 'a per to construct and install the work herein <br /> described. Th'is application ;is made in compliance ith County Ordinance No. 549 and existing Rules and Regulations: <br /> 1 <br /> ;JOB ADDRESS/LOCATION ...Pll - --- I .S--- /+ ------.5; CE 5N U5 T A T __ --------- <br /> Owner's Name -- -------------------------------------- '---------------.Phone------------------• ----------- <br /> Address ----- = _ — n 0= --• -''f 1 -----------------------• city v"C1 --------------------------------- ----------- <br /> Contractor's Name U��c � 1 ---- ----------License # Phone �_ <br /> r -Installation will serve: > Residence 24-Ap5c!rtment-House°❑ Commercial ❑TrailerCourt ',❑ <br /> Motel ❑Other -------------------------------------------- /y l <br /> i Number of living units:__ ,/___ -. Number of • rooms _ Garbag rinder Lot Size -/ 7-- ----- <br /> kT Private' <br /> Water Supply: Public System and name -- ------ -- - ------ ?---- ------ ------ ---- ❑ <br /> Character of-soil to a depth of 3 feet: Sand•'❑ ilt❑ f G�il <br /> Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe' gterial ----- If yes,type ------------_-----________ <br /> } <br /> (Plot plan, showing size of lot, location of`system in relation to wells, buildings, etc. must be placed on reverse, side.) `t <br /> NEW INSTALLATION: AtNo septic tank or seepage pit perVe_ _ <br /> ' ublic sewer is ovaifal�le"within 200 feet,) W <br /> PACKAGE TREATMENT { ]r SEPTIC TANK' � ________________ Liquid Depth a---�--- <br /> Capacity J' Type - teria --`_ - -- - No. Compartments __-_-_ <br /> ' ---- j __.__ Pro Line f <br /> Distance�tonearest: Well __ -_____________Foundafio, _ p. <br /> LEACHING LINE .�-I No. of Lines ----- --------- Length of each line__ • -YY----- Total Lenthe„__�,/ --�_______ <br /> j 'D' Box _ Type Filter Material -- Depth Filter Material ___ :_..____.- <br /> "__>•_ Distanc o nearest: Well _-__'_77:7=n-------- Foundation -404----------- Property Line, A-5--_____________ __ <br /> ~- ____---____ Rock Filled Yes :[ Kio i❑ <br /> SEEPAGE PIT [- Depth -------------------- Diameter Number ----------------- <br /> Water Table Depth -/�--�-/------------------ Rock Size <br /> i Distance to nearest: Well ------�~-------------------Foundation ______ Prop” Line -%5------------------ <br /> REPAIR/ADDITION <br /> __f___________REPAIR/ADDITION(Prev. Sanitation Permit°# ___-_- ------------------------------------------'---------------=-- Date ------------------------------------ <br /> 1 � : <br /> I i <br /> Septic Tank (Specify Requirements) ___________________,__________ <br /> Disposal Field (Specify Requirements) --------------------------------------------------------------- --------------------------------------- ------ ------ <br /> i <br /> -------------------- ------- -- <br /> - ----------------------------------------------------------------------------- --- --------------------------------------------------------- -------------------- <br /> --- ---- -- --- - - - - ---------- ------ <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 withiSan Joaquin <br /> i County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> l "1 certify11hat in the performance of the work for which this permit is issued, 1 shall not employ any person im such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> + Signed -------------------- - ------------------- ---- - --------------------------------------- Owner <br /> BY Title <br /> (If o e han owner <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED' BY DATE -, x- ._ �--------- <br /> BUILDING PERMITISSUED -- ------------------- -------------------------------- ----- --------DATE ------------ -------`------------------ <br /> ADDITIONAL`COMMENTS -- ---------------------------------------------------------------------=----------------------------------- I----------- --------------`-------------------- <br /> S ; <br /> ----------------------------------------------- ---------------------------- ----------------------------------------- -`---------------------------------------------------------- <br /> j <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------'-----------------------------•- <br /> Final Inspection by: _._ �: -----------------------------' <br /> Date _ ' -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 µ 1-'b8 Rev: 5M _ _._. z _ C <br />