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FOR OFFICE OSE: <br /> APPLICATION FORSANITATION PERMIT <br /> q t ? D {Comple#e in Triplicate! Permit No. . ..... <br />...�'.` ....... .....J.....--•-- <br /> ' Date Issued <br />• ••••--- ............................... This permit Expires l ,Year From bate Issued <br /> t0 I <br /> Application is hereby made to the San Joaquimitocal Health District for a permit to construct and install the work herein <br /> described. This application is made in complioKiic with County Ordinance No. 549,ond existing•Rules..and-Regulations: <br /> JOB ADDRESS/LOCATION .. . ,.,`T..1� ... . -rJ �.�, --- -----...- <br /> QQ ....................CENSUS TRACE �J ..... <br /> Owner's Name :....... -------------••-------------- ----P 3�` 5..`��.......... <br /> Address. „� � � � 1 <br /> hone 9 <br /> �.. .... 1'7_._.. Q?S�/. .0ry__1----._. Cir . ~x.... �1 ---- ------ <br /> Contractor's Name ...._..- ....... . . .. _.............-_..License # .oZS`�.�.cf� Phone <br /> Installation will serve: Residence ❑ Apartment House, Commercial OTrailer Court <br /> i—Motel-O'Other <br /> t <br /> Number of living units:......._.. Number of bedrooms _...!Garbage Grinder Lot Size ... ............. ... <br /> Water Supply: Public System and name ------------ ----- r------- ------------------------....---------------------- ivate)9f <br /> Character of soil to a depth of 3,feet: a. Sand.C] Silt-QSCloy ❑ Peat❑ Sandy Loam D Clay Loam`` <br /> Hard an; .. A Ad`obet Fill Material -.- -. • If yes, type ---..__ .... .............. <br /> (Plot plan, showing size of lot, location of system lin relation• to wells, buildings, etc, must be placed on'reverse side.) <br /> NEIN INSTALLATION: (No septic tnk or seepageit permittedi public sewer is available within 200 feet,) ; <br /> PACKAGE TREATMENT ] ] SEPTIC TANK Size.....--. ---?<-- •......................_ Liquid Depth ...��_-............or <br /> Co aci yl "Type <br /> ........ Material. .. Na.' Compartments ... ~f......._..V# <br /> Distance to nearest: Well -----------------Foundation ..../0... Prop. Line ..47-."7........ <br /> .� <br /> LEACHING LINE No. of Lines l . __.. _. .. Length of each line ../.. ............... Total Length ---------- <br /> ,'_VD' Box Type Filter Material ..00 ....Depth Filter Material .._._�. '_.�_�., ._ <br /> I VN <br /> f r r <br /> Distance to nearest: Well ... 0•-"t---_---- Foundation �D......... Property Line,R�.._�` <br /> SEEPAGE PIT 17epth ........ Diameter ...... Number .............. Rock. Filled Ye's,K No <br /> Water Table Depth . <br /> ------------ -------------------•---•-•------..Rock Size ..���-. rgi. '/-:_ •+ . <br /> r p Foundation._© r `�. ' .._ —f <br /> Distance to nearest: Well -•--� ---- -----..----- 'Prop. Line' S........... <br /> REPAIR/ADDITiONj(Prev. Sanitation Permit# .............. .......__.. Date ... ...... v <br /> Septic Tank (SpJcify RequireIents) ... ................................................. T r % <br /> Disposal Field (Specify Requirements) ....._---------------------------- <br /> .................... ....... ............ ...------. . .. -- ....-----......------.--- - <br /> ...... .. ........... --...........--- r--o-- - .:. --- ....... . ...........-......... .......... ............... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify thit I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances., State taws,',and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen. <br /> sed agents signatu;e certifies the following- <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subiect to Workman's Compensation laws of California."I <br /> Signed - -- ........ .. .......- �... Owner <br /> F t <br /> BY ... -� -��PA�RTMENT <br /> . ,Title . • . <br /> (If h r than owner) <br /> USE ONLY <br /> APPLICATION ACCEPTED 8Y .... ... ....... ........ DATE /r'yt/..-._.... <br /> BUILDING PERMIT(ISSUED .....-- .....DATE . . -•-.----------•-... ...... <br /> ADDITIONAL COMMENT ...... . <br /> �`� ; - j �c; --::-- - ---------- --...... ------- •• --------..::..: ::: : ----------.------------. . : : ::::..... <br /> ....../..-..... --- ---- •. ....... -•--- ....... .. ....I..... ................ ..................... <br /> ----•----..I....I.,----- --- <br /> Final Insp&i6A-by: ........... . ................................:.................._.......---Date <br /> NQUIN LOCAL HEALTH DISTRICT <br /> 6 � <br /> ._H.1.3 241--68-kev• 5M . ... .: :, * .. :�=` 7/723 ,1.4 <br />