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FM OFFICE USt:: <br /> x APPLICATION FOR SANITATIONWIT PEP <br /> Permit No. <br /> ................. ...................... - :(Coarplete In Trtplicote) •. q" <br /> .. :� ... . .:. ............ . _ Date Issued .. y✓51.. <br /> This Permit Expires 1 Year From Date Issued <br />........................................................ <br /> .Application Is hereby made to the San Joaquiri local Heaith Distilct for' d permit to and Install <br /> the 'wot'k.4teroin <br /> described. This application is madein cam piIonce'with'County �dlnanceeNNo. 544 and a lnp Ruiei:and Reguiatlonsi <br /> RE LOCATION �� .<• . .:. ......� I. ... .... . . CENSUS TRACY <br /> 308 ADD SS/ ."` ,(•. <br /> ..Phan <br /> Owners Name .-._ . .. ... ../....<..... •.............................. fF <br /> Address ................•••••....(/.= .. �-•- .........City <br /> Contractor's Name ...:License ......_. . <br /> ........ Phone .. : <br /> .••••---.....•---... .- --_._— <br /> Installation will serve: , ResidencoAApartmeniftuseO Commerdal❑Trall ❑ - : <br /> w Motel (]Other,--_.. ............................ >, <br /> Number of living units:__•r.-1.... Number of bedrooms .. ..Garbage Grinder Sr1ie. - : <br /> Water Supply: Public System and name ...••..........................-----. ...... .. <br /> Character of soil to a depth of 3 feet: Sand 1:1 Silt❑ Clay [j Peat C3 Sandy Loam day Lou ❑ <br /> Hardpan❑ Adobe❑ Fill Material ............If yes.type............ .... ... ` <br /> i <br /> ,Plot plan, :hawing size.oft,lo ,locationofT:ystem.�ln,rslat�on_ to�-wells,_buildings,.ate-,must be- placid ,reverse.side.) � <br /> NEW INSTALLATIONS (No septic tank or see go plt permitted if public sealer it available within 200 fee ,] <br /> PACKAGE TREATMENT ( ] SEPTIC TANK Size...........�.......... ............ Liquid Depth --.. ..........E ,) <br />' Capacity 1. ►.,.4Ty !� -.C�.[J.•MaterialN .°.... No. 6ompartr�nen .. •� <br /> � � Pro Li .:� .. <br /> W <br /> Distance .. . o nd .... <br /> 'to :near <br /> est: <br /> 'f'"u anon; .� • - p' .� <br /> EACHING LINE No. of i_Ines .-. n ! ` -- Total L`eng .. ._..... <br /> 'D' Box ..•.:f . Type liter Material �IG.-- pth Filter aterlal 1• .. <br /> Distance to nearest• Well ....� ... Founds. on .. ...�- Paper t L! •� <br /> 4 + <br /> EEPAGE PIT [ ] Depth Diameter ................ Number ....... ... .......... �toc No <br /> .. ..Rock Size <br /> Water Table Depth <br /> Dista a—f6jnea est: Well.........................•�'.. '" _ ...Foundation'' p pr'p. L e .............. <br /> 4 EPAIR/ADDITION(Prov.Sariitation`P' rMI#` � .................••- ` . _ .. . Date ........---........, ,.. ........1;6;�' ] <br /> Septic Tank (Specify RegvIr'e_m r_6 69:' ........................ • ............................ . -.... . ..............._................ <br /> Disposal Field (Specify �equiremants] ..... ........ .......... ................ ......._. k '��...._. ............. ... <br /> S Y <br /> t ............................................................... ...... .... .. <br /> 1 ........... ...... ..........................___ ----...---............•-_. ... <br /> ......... ......._ .. ........•..-----.._.._... <br /> .. <br /> 3 <br /> (Draw existing and required addition on reverse side), <br /> hereby certify that I have,.prepored thh-application'and,th of the•4i ork will be dense In aa>frd th San leaquin <br /> ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local'Health District. Ham k owner or llcsn, <br /> led agents signature certifies the following: <br /> N certify that-in he.Performanse.of.the work for which this.P ermii..is Issued, 1 shall pot employ any eno Ira such.ntaitner <br /> as to becomes jct to works o► on laws o a i o <br /> .. .r <br /> Signed net . <br /> .............:.....:..._:.........:.......:.:._.....:.......... <br /> ......ail•f .....-..• •. .••.•.,._•- ;i <br /> }Ft4 .. ae..MR!_MNIaM•-_ono-���i ........ 11 <br /> if other than owners <br /> E FOR DEPARTMENT USE ONLY <br /> : <br /> APPLICATION ACCEPTS© BY ..:........ ..............................:.. ............-............... DATE .... ..,/,� <br /> .......... __ <br /> BUILDING PERMIT ISSUED .....:. .. ...... - - <br /> DATE>.: <br /> -- <br /> ADDtTIONAI COMMENTS .... <br /> ................. :....... .............. ..------ <br /> .............---- --.......................................... . ......_....................Dat...............�r� .- -.i ......... <br /> Final Inspection b <br /> - -................... <br /> P Y ..... <br /> ` Eli 13 2h 1-613 Rev. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H <br /> i , <br />