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i' / uk c� <br /> f+r L4 T 2z s� 'F oo7s'-"' <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT Pfr FOR OFFICE USE: J <br /> # (Complete in Triplicate) Permit No._____ <br /> Date issued.__._- <br /> -�-/ e'�;'l <br /> ------------------- ------ This Permit Expires 1 Year From Date Issued <br /> Vi <br /> Application is hereby made to the Sci-ri"Joaquin Local-HeoIth'D'istrict forja+permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. nd existing Rules and Regulations:,. <br /> JOB ADDRESS/LOCATION---.`2Z_-----.----- ._ _ --y-- ---�3f/rfi(JDU 4 _ 'rENSUS TRACT------=-------------------------- I <br /> Owner's Name - <br /> - -- Z " <br /> --------------------- Ph �, <br /> Address... �.3r - .-�lON-.----s ------- ----- =--- --City 't=ora Zi <br /> Contractor's Name--- ----------------------------- -------------------- - --------------- <br /> --------------- Phone <br /> Instal lation,will'serve: Residence; Apartment Mouse.© /Commercial ❑ Trailer Court ❑ <br /> k Motel.[] Other ---• -- J <br /> Number.of living units:-.--..---/ ----Number"of.bedroom s ----_GaJrba /a <br /> Grinder_• ___,: _ <br /> ot.Size-----_--- - ---------------- <br /> Water Supply: Public System and name------------------ __- ___ __�.{ _ Private ❑ + <br /> Character of soil,to a depth of 3 feet: Sand Silt❑ Clay 0 Peat❑ Sandy Loam ❑ Clay Loam ❑ s I <br /> .- f t <br /> Hardpan ❑ Adobe'n Fill Material- `c.-..__If yes, type£ - -._- 77771-------------- <br /> h <br /> (Plot plan, showing size of lot, location of system in relation to.wefls, builclings ex mpst�be;placed on reverse side.) e <br /> NEW INSTALLATION: {No septic tank or'seepage pit-,permitted if public sewer is avai ble within 200 fest,} <br /> : <br /> PACKAGI_ TREATMENT ..�+""" /�eJ v L = Liquid Depth ------------------------- <br /> -2 <br /> e <br /> f <br /> [ ] SEPTIC TA5ize :__`.__�____.____._�- - - <br /> Ca acit 1po- 1 tP aterial__ � �- p --f <br /> p. Ype �` >� No. Compartments ------ -- <br /> Distance-to nearest: Well .._ __ _____---- i Foundation r _.•__Pro Line.. ------------------------ <br /> I1 <br /> t r } c,� P•LEACHING LINE No. of Lines..........a2 �_ X <br /> I)Qt _..Length of eadh line _ __ _. To ai�Lengt�----------- <br /> ------ <br /> f/ c„"- CTC = wi <br /> D' Box :._Type Filter Material;�y. _Z_ e Filter Material._ �'�% i 'C'' <br /> t s <br /> Distance•to nearest: Well-----------------------.__`Foundation----,--------------s_ _ __Property Lin ------------------------------------ CG}ti <br /> ' <br /> SEEPAGE PIT [ ] = Depth----i------i----diameter_--------------------Number----------- <br /> ----------- i Rock#Filled Yes.❑ Noy❑ <br /> .. ..«- _. <br /> Water Tabfe'Depth--- --- --- --- '' .Rock Size fir'' r <br /> __.____. ,Foundation. � PropLine _ <br /> Dista--rice,to nearest:Well + <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-- _tit ___ Date.\ <br /> ss <br /> -- <br /> + `Septic Tank (Specify Requirements] ------- --------�-A--------- ------------ <br /> -------------- <br /> - <br /> -- -------------- <br /> Disposal Field (Specify Requirements)'___- __ ' --------- <br /> yy <br /> �_ _ i f <br /> ------------.-------------______--------_____---------------_------------------ --------------------------------------------------------------------------------------- -------------- ------ -- -- ---- <br /> � <br /> (Draw existing and required addition ori reverse side) { <br /> I hereby certify.that I have prepared this application and that the work will be done in accordance with San Joaquin. County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: i <br /> "I certify that in the performance of the work"for which this permit is issued, I-shall not employ any person'in -such mariner as q <br /> to becomesu ct�Work n's ompensation' laws of California." , <br /> Signed ------ ---- Owner ` <br /> _ . <br /> BY ------- ---------------------- --------------------- <br /> :------'-------------------- ----:Title---- -------------------------- <br /> ` ' - - ----'-.--- - <br /> (If other'than'owner) <br /> T USE ONLY <br /> FOR DEPARTMENT <br /> APPLICATION ACCEPTED BY--- ----- -------------DATE-------r'�-- 7-. <br /> DIVISION OF LAND NUMBER:' --------- -------- ----- ---=--.DATE-------------- -- <br /> ADDITIONAL COMMENTS----- -------- ----------------------------.------- ------- ------------ <br /> -------- ----------- <br /> -------------------------------------------- ------------------------ ---------- <br /> ----------------- <br /> ---- ---------------------------------------------------------. - '----------- ---------- <br /> 1� = -------- ----- <br /> Final Inspection - :Date--'- <br /> EH <br /> -------- ------------ <br /> EH 13 24 , S N JOAQUIN LOCAL HEALTH DISTRICT 6l?2 Nt)I- J;r4d-9r`Fr°41677 REV. 71763M <br />