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FOR OFFICE USE: <br /> FOR OFFICE USE: I <br /> !.,L: a(� APPLICATION FOR SANITATION PIRMIT Permit No._7._9..,.J_4L <br /> ............ (Complete fis Triplicate) <br /> ..................... u I Date <br /> This Permit Expires I Year From Date Issued <br /> .. ........... ........... ...... .......... <br /> Application is hereby mode to the Son Joaquin Local Health Distrid for a peimit to construct and install the work herein described. <br /> iRules and <br /> This application issade in 5mpllance with Co �ty Ordincnce No.�49 and existing Regulations: <br /> -V , <br /> ........... ........ <br /> JOB ADDRESS/LOC�T�N..N,- tlla ;'�CtNSUS TRACT...... • <br /> ............. <br /> -----Phone <br /> Ov�ner's Name.. <br /> city 7--i..........I.Zip--- .......... <br /> --------------- <br /> Address-_ --- <br /> icen .. . ......... - --- -- <br /> ---- ----------- ..... .......... ­....... L <br /> Contractor's Nomd I-- -1 ----- t26 Be --- Phone ------- ------------ <br /> V. <br /> 4 t House C1 Commercial Residence tl- Apartment ;'ci;l�j jroilor-Court C1 <br /> Installation will.s Resic !I � / <br /> M8tel-[] •Other:..... ------ --------- ...... <br /> ............... <br /> Number of.livini units:-,I-.!--------..Number of bedrooms.?'__,2.-._.Garbcjge Grinder. <br /> ..........Private <br /> .............. <br /> Water Supplyt Public System and name.... ...... .......... --------- >11 a J& <br /> cloy 0 Peat Er Sandy Loam lay �ocim 0 j1Z: <br /> 'Silt[I am <br /> Chbrocter of sail to a depth of 3 feet: Sand [I <br /> Hardpan r7 Adobe'{] Fill Material............If Yes,type----_----------------- ...... <br /> (pl;t plan, showing 'size of lot, location of system in relation to wells, bulldihgs,;etc. must be placed on reverse side.) W <br /> '(No septic tank'or seepage pit p if p6bilb-sil; available within 260 feet,) j <br /> e ver is <br /> NEW INSTALLATION" t I I <br /> I - q '. - Liquid Depth.:....-....^...I:......'. <br /> PACKAGE TREATMENT I '] rSEPTIC TANK -[1j-, Size_'_...t--:%-!------ <br /> �.:t Compartme......Material...t..........: ....:(-I:IJo.Capacity........:...............Type:... ..........Pr6p. Line...... .... ..DIstance'to nearest;Well........ ..... .......... ......... ...f h ol each ...... -- .f.;....Total Length I <br /> No, a Lines <br /> LEACHING LIN } _:_----- ..........._._1engt <br /> 'D' Box..:.....-,..Type Filter Material:---_---...__:---Depth Filter Material.-I......'.....---- .......I.... ........... <br /> PZpstperty <br /> y Line.................... ..........;-I <br /> Distance to nearest:Well...............:............Foundation... <br /> Rock Filled Yes[I 'NO <br /> SEEPAGE PIT` I I Depth--..:......'.....Diameter..:......7- ...Number..... <br /> Water Toble.Depth...................... ... ..................:.........._Rock <br /> ................. ......... ......................:.._,Rock Size. -.:.' 4 <br /> undotioln....... - 'Prop. Line........................... <br /> ni:e to nearest:Well.... --.....Fc <br /> .............. <br /> Disto <br /> 3te .......... c5 <br /> REPAIR/AJ)DITION (Prey. Sanitation Permit#.........t._-.........I...... .........D4 ..... V X <br /> ............ <br /> Septic Tank(Specify ............................. ..................... <br /> A __ ................... ......1 .............. <br /> Field(Specify Req ...... ------- <br /> DISPO: Requirements):. -viremeni .... ....... ...... ......... <br /> Ut-- <br /> ... . ........ ------ ----------- <br /> ............. ...................... ........ ................. .......... .......... ....... <br /> . .. ... (Draw existing and required addition on reverse si de) I <br /> be done 1n�isccorcicince with Son Joaquin County <br /> I hereby-cattify-1hat I have prepared this application and-thatthe ;work will <br /> 'istrictilriome owner or licensed agents <br /> Ordinances,' State Laws; and Rules and Regulations of the San Joaquin Local Health 0 • <br /> signature certifies the following; <br /> I certify that in :the Performance of.the work for which this permit is Issued, I shell not *MPIOY any in suc manner as <br /> to become SU616cf.to Workmanis COMP.ensation laws of California." <br /> Owner <br /> ........... .... <br /> ------ <br /> Signed-=-----'----- ................. <br /> t ----IJ---------------- ------------- - - _ <br /> EEE <br /> (if othei'than owner) <br /> ---*Ml DiijARTMENT-USE-ONLY' + <br /> . .....I .— J" :_..... *� XE-J------- ...... <br /> EPTED�BY . ........ ....... ......DA I <br /> APPLICATION .......... ............--_...DATE.:......:. ................ <br /> DIVISION OF LAND NUMBER..............:.....:..........•.------- -- <br /> ....................................... .................. .............................. ................. ....... <br /> ADDITIONALCOMMENTS--- ---------------------------------- -------- ............ ........11------------ ...... .........._..... ...... <br /> --------------------- ------ ......:........... ............ ..........................:..........................:-------- <br /> ..................................... ........................ -------------- <br /> ----------- ................................. <br /> ......... MY <br /> -- -------- <br /> ................. ...............*..... . <br /> Final Inspection by:.........t. ------ F&S 21677 REv.7/74S 3 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />