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� rvR vrriu me, APPLICATION FOR SANITATIGN. PERMIT <br /> ................�+_.........�.......................--•-- Permit No. <br /> '..................... <br /> (Complete In Triplicate) ._.... . . <br /> ... .. . . .................. <br /> v Date Issued . <br /> ................7� <br /> This Permit Expires I Year From Date Issued <br /> ................. ... . - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construd and Install the work herein <br /> described. This application Is made In compliance with County Ordinance No. 549 and existing,Rules and Regulatlonsi <br /> f� <br /> JOB ADDRESSAOCATION ....... ..1.-. ...............:..........L3.0 !� Imo............... .......................... <br /> e CENSUS TRACT <br /> ... .. 4: ......:............................ <br /> ...........................- <br /> _ ,� .r ;a.. <br /> . �' . ...........-'.. '_`........................................:.. :: :City ......................................r <br /> Contractor's Name _.... . E• � ° ,L.IF,...................................License#412.2 - ......• 1 <br /> Phone <br /> installation will serve: Residence Apartment House} Commercial❑Troller Court ❑ <br /> Motel❑Other............................................ <br /> Number of living units:-1...... Number of bedrooms .............Garbage-Grinder: .... - <br /> -Lat_Sizek .................................... <br /> Water Supply: Public System and name ................ ..........».... .... -. .Private <br /> of soil to a depth of 3 feett Sand 13,- Sllt❑ {Clay ❑ Peat C3 Sandy Loam [] day Loam ❑ <br /> 4 <br /> Hardpan❑ Adobe Fill Material ............if fres,type.............. ...........: ! <br /> (Plot pian, showing size of lot, location of system-.In._relation..to=wells,,buildings-etc.-must.be.-placed on reverse slde.} <br /> NEW INSTALLATION: (No septic tank or seepage it ; <br /> Pp permitted if;public %wer is available within 200 feet,) t <br /> jj <br /> PACKAGE TREATMENT ( ] SEPTIC TANK{ ] Size---5�:. .�,�.. a ................. Liquid Depth <br /> it �? '� . 6 <br /> .7Y +.... <br /> Capacity l .r .......--- <br /> •. Type ....... . ....... No. Compartments <br /> 17 <br /> Distance neareaWell ......................' --.Foundation Prop. Line ........... <br /> LEACHING LINE ( ] No. of Llnss,�n...I.......nongth_of each Il .t.......... Total Length '6..s..:a:..... <br /> 'D' Box ..1:...'�YTypa Filter Materlal,i%. Depth Filler Material .. ... . ,T <br /> 10 t Distance to nearest: Well . �?.........:. Foundation -QS. PProperty~.Line . ............• ''. <br /> SEEPGE PIT ' ' <br /> A _ ( D Depth .................... Diameter . .......'. Number./".*. ....................... Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ............................... . F...........Rock Size ................................. <br /> rDistance to nearest: Well ......................................... Foundation ................ Prop. Line .............•--...... <br /> 4 REPAIR/ADDITION(Prev. Sanitation Permit# ..............................r.. .......... Date ................................ <br /> } ' <br /> . Septic Tank (Specify Requirements) ....................................... <br /> ......................................................... <br /> ........... . . .............».................::"� ...... ! <br /> Disoosol Field (Specify Requirements) ................................. <br /> .............................. ....`............. I .............................. <br /> ..... .�.................. k...... <br /> # - +p ........---•----- <br /> ., --•---------_.......................................................................box. .........•............•....i ..............................I......�.............�• •...•-.•....!...... <br /> f!Draw existing and required addltlon ori revers..side}..................................................... <br /> ................... •'•-------- ......................... <br /> ........... .. ; . .. <br /> i I hereby certify that I have prepared this application and that the work will he done In accordance with San Joaquin <br /> County Ordinances, Stale Laws, c d Rules and Regulations of the San Joaquin Local Health Dlstricf. Home owner or iicen - <br /> sed agents signature certifies the foflowing: <br /> '°I certify that In the perform nce of the work for which this permit is Issued, I_shelf not employ any;,persen In such manner <br /> ,. ---. <br /> r as to become subject to W m •s Co Me on laws of California." <br /> a. ned <br /> g ' - ......................................................... . Owner <br /> ay •----- ................................. Title i <br /> Of other than owners <br /> i FOR DEP JIAENT USE ONLY <br /> 4 _ <br /> APPLICATION ACCEPTED BY-..._ DATE ..... �, <<L`-... ... <br /> BUtLDING PERMIT ISSUED "b <br /> "r .. — <br /> . .. <br /> ADDITIONAL COMMENTS r ...... ...._. ....._.. � .......JJ.��.�..-��•- ----. . <br /> - ---------- ....... . . <br /> .... .......... ......-I!............. <br /> . . <br /> ............. .... �� <br /> ........ <br /> final Inspection by: __....----•• - ....Date .... .- .=- <br /> EH <br /> 13 2!, 1-611 lay. 51�f SAN JOAQUIN LOCAL HEALTH DISTRICT '8/7h 3M i <br /> .� I <br />