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rva �r'r7� 1.IJCe <br /> APPLICATION FOR SANITATION PERMIT � <br /> ............................................. (Completo In Triplicate) Permit No. . ... ...... <br /> .... ... This Permit Expires 7 Year From ate D Dab issued <br /> . . <br /> ► Issued <br /> Application is hereby made to the SanJoaquin local Health District for a permit. to constnid and install the work herein <br /> described. This application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulatlons: <br /> JOB ADDRESS/LOCA `�� (.l..... ..*.. ..... ............ <br /> CENSUS TRACT ........... <br /> ............... <br /> Owner's Name .. ..... / Phone ~ . <br /> Address _?' .......... ( .. . <br /> ... .........------......City •--��e-1J...................................................... . <br /> Contractor's Name .... F. a... 1�ld .. .xL ...........................License # 4a.?9ra.7J.. Phone . �df.s '•3. a -: <br /> Installation will serve: Residence❑Apartment House Commercial QTraller Court ] <br /> Motel(A Other............................................ <br /> Number of living un#s:............ Number of bedrooms Garbage Grinder Lot Size .s�:.Q.X. . <br /> Water Supply: Public System and name ........a�.... `'V-•----....•._....---..........................................o�. .. <br /> .... Prhrah❑ <br /> Character of soil to a depth of 3 feet: Sand 0 Slit(3 Clay Q Peat Q Sandy Loam fl Clay Loam <br /> Hardpan p Adobe Q Fill Material............l#Yce.typo............... ............ Q§ <br /> IPlot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feat,) <br /> � y <br /> PACKAGE TREATMENT [ ] SEPTIC TANK( j Size................................................ liquid Depth .........................f. <br /> Capacity .................... Type .................... Material...................... No. Compartments ............ <br /> Distance to nearest: Well' ..................Foundation .......... Prop. line . <br /> LEACHING LINE No. of Lines .. Length of .each line...................... .. Total Length ......... • <br /> 'D' Box ............ Type Filter Material .....................Depth Filter Material ............................................ <br /> 10 Distance to nearest: Well .............:......I... Foundation ........................ Property line ...................... <br /> SEEPAGE PIT [ P Diameter . <br /> Depth .................... _............ . Number ----•------._............... Rack Filled Yes Q No 0, <br /> WaterTable Depth ................................................Rock Size ............._ ................. <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> ZEPAIR;�DITION(Prov. Sanitation Permit# ....... _I.............•1................. Date ....... ....... ... .I <br /> Septic Tank (Specify Requirements) ......A2A .::..Y.d '... . .._f.-........................ <br /> Disposal Field {Specify Requirements) Jr, <br /> ._..... - -- .......................................................................... <br /> ............................................................................................................_............................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with Sen Joaquin. <br /> County Ordinances, State Laws, and {tyles and Regulations of the Son Joaquin Local Health District. Hem* owner or licew <br /> sed agents signature certifies the following: <br /> "1 certify that in the performanco of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ... ' ' !' ner <br /> .Q ' <br /> /ll..: G �......._ - title .. <br /> BY .. <br /> .. . _ ..: .......... .. .:..... ................. <br /> ....... .................. <br /> (if other than owp <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ......... - .. ................. DATE <br /> BUILDINGPERMIT ISSUED .....................:................. ...........:...................................................DATE ........................................... <br /> ADDITIONAL COMMENTS ... ........ ------ - --. ... ,........................... <br /> .._......( ! � 71a.... .rte---.1 ......-..... ......................................... <br /> .... .........:......................I.............. <br /> ............................................... ...........................................I...••.... .._......_..........._........... ............................ ....................... <br /> :.....-..._... ...................................... ....... .... <br /> finalinspect:'on by. .._...... __ ... .... -• .............................................................................Date ...----- <br /> EH 13 24 1-" Rev. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H <br />