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� <br /> FOR OFFICE USE: ., 'fAPPUCATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> _.__......... 4ti+7 P P Permit!NoC�1...�..Y".•�.- i <br /> ....,a•. -"-"""" - - r (Com le» In Triplicate) t <br /> ... ...................................... Duro issued.fa.- <br /> 1 ---..---_-__....__................_...._.. This Permit Expires i Year From Date1111111114011 <br /> is hereby mode to.the San Joaquin Local Health District for a permit to construct and_install the work herein described. <br /> This application is made-in.eempliance with.Coumy Ordinance No. 549 and existing Rules and Regulations.- <br /> 1 <br /> egulations: <br /> 1 1% p I I <br /> JOB ADDRESS/LOCATION....i?/.3.Q�-.. If.M4.P.lt.....1.`.Wr..................................:.............CENSUS TRACT_- .......:.......-.....------ <br /> t ........ <br /> phona.. .7._-'�r.. <br /> Owner's Nome.... .. .4.t.�...�.•.. Y.Q.M.R.............................................................._. ....... .....- ...... .T..... <br /> Address................ 2.0, �i�lc.. o�................�_.............._. .--- ..._ciy...(.:�fe� .011-S....�...._.....zlp..�VA ;.......... .. <br /> Contractors Narsre.:....GC�J. �.�..�.....-�.... ........ ....:0............Lioenso # - ;�- ._1...Phone.......t._....................... <br /> Installation will serve: Reside�tce A rtment House /,�a- ❑ Troller Cort ❑ <br /> Motel Q Other....nia C.opn..x.�ll..� 1-I 5_�'� .• <br /> Number of living units:.. _._.......Number of bedroams.wl.�.Y...Gorbage Gti'-oder:V'.._.lot Sitte.--•--------,"-�-��� �- •--'•""'-"" " 1 <br /> Water Supply: Public System and name:'......G.<'(..f!�C.t.............. ............:..'......... .............. . ........ _...- Ivat ❑ <br /> ...Pr s 1 <br /> Character of soil to a depth of 3 feet: Sand❑, Silt Q Clay❑ Peat❑ Sandy Loam❑ Clay Loam ❑ . . . <br /> Hardpan CW" Adobe❑ - Fill Material.. ._. _..If yes; type--------------------"".... <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted..if,public sewer is available within 200 feet,l 4 lr <br /> i <br /> PACKAGE TREATMENT ( I SEPTIC TANK 1 Size d*.7 Js---/•--•-------------- Liquid Depth...-`. ... --- - -•S� <br /> Capacity, - Q --- T QQ . ateral..._.— .............No. Compartments <br /> . 114. r 1 r -- ........T <br /> . oProp. line..... ........_.......... <br /> .......... ......._FundaHon..._Distonce to nearest: e .--- <br /> 0 <br /> r <br /> LEACHING LINE No. of Lines . ._. ........Length of each fins...... .... <br /> .............:...Total Leith ................... <br /> D' Box: . . Type Film Materlai�L��t�...Depth Filter Material....... 9---". .-- - - - " j•• - <br /> �/�� r n r <br /> �- s�H n Distance to nearest: Well._.ale! ..-.--.--;---Foundatlom...... Line...-,r.,a. ..................... i, <br /> SEEPAGE PIT t,_70Cf/' Depth . Diameter_.................Number...........-- .........-....... �/ .r Rock Filled Yes10 ❑ No <br /> r Z error Table Depth.... ...........Rock Size....s•� .1......... ..................... <br /> 4 Distance to nea�t�est: Well...^.....................__...........-. ^•......................._.Prop. Line._- ---.------- r <br /> REPAIR/ADDITION IPrev. Sanitation Petmit#......____ ...............Dole....._:_.................................. <br /> ) . <br /> Septic Tank (Specify Requirementsl........f......... .............................................._................._........................_--------:------............ <br /> ,;_.:,.... <br /> Disposal Field (Specify Requirements)... ........... <br /> equirements).............. ............_........_... .._...........»._...a......_..................._...._..-.-_........_::...;,.---....._. <br /> s <br /> ....._..._ ......__..................................._.......... . <br /> ................_............_...................... <br /> (Draw existing and required addition on reverse sidel , <br /> I hereby certify that I have prepared this application and that We work will be done in accordance with San Joaquin County 1 <br /> Ordinances, State Laws, and Rules and Regulations.of the ,San Joaquin Local Health District. Home owner or licensed agents 1 <br /> signature certifies the following: <br /> "1 certify that in the performance of the',work for which this permit is issued, I shall not employ any person In such manner as <br /> to become subject to Workman's Compensation laws of Califomia." r , <br /> Signed...._.............................._......................'--;-'-._._.........................Owner— <br /> t # .......... <br /> (lf other than owner) <br /> n R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ......DATE .SR.'Tat-7.- 1�r--.-- ------ <br /> DATE <br /> ---- ---" <br /> ��J <br /> DATE....-..._........... --- ................ <br /> ntViSION OF LANG NUMBER ..................................... .....................................----......--- <br /> >ITIONAL COMMENTS.. ............._f .... <br /> .......... <br /> _.................... <br /> ...... <br /> .... <br /> .--- <br /> .---------------------------------------- <br /> ...............----......... ....... ._..... ......_. <br /> .................... . <br /> 49 <br /> Final Inspeenon ..................... ............ <br /> '7f <br /> t M 10 N SAN JOA ClLOCAL HEALTH DISTRICT .•-- -. sss 21677 ssv lire tM <br />