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r-OR OFFICE USE: FOR OFFICE USE, <br /> APPLICAXInN FOR SANITATION PERMIT 78.30? <br /> Permit No. <br /> ........... ...... ........ . (Complete In Triplicate) <br /> ........................... .... Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein dewibed. <br /> This application is made in complliance-with County Ordinance No. 5549 and e• ng Rules and Regulationst <br /> JOB ADDRESS/LOCATION4r;n <br /> �[/ . . r"1 CENSUS TRACT <br /> iz�,�o.Q Phohr�-z6f-.03/5... <br /> Owner's Name / c <br /> Address_ ! ` ,� City Sw� /� ZipContractor's Name �-� license I ��; Phone <br /> Installation will serve: Residence'( Apartment House❑ Commercial❑ Trailer Court ❑ <br /> Motel ❑ Other UU '- <br /> Number of living units: t/ Number of bedrooms Zriorbage Grinder Lot Size .��r x�T <br /> Private��, <br /> Water Supply: Public System and name <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Cloy❑ Peat❑ Sandy loam Clay loom <br /> Hardpan❑ Adobe 0 Fill Material If yes,type <br /> (Plot plan, showing size of lot, location of system in relution to wells,buildings,etc.must be placed on reverse sidp.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available withir 200 feet,) <br /> PACKAGE TREATMENT I ) SEPTIC TANK N Size. S X t?.. liquid Dept', •... <br /> Capacity 1A.70 Type. Material e-01144-o No. Compartments <br /> r <br /> Distance to nearest: Well . <br /> Foundation 4/0 Prop. Line ... <br /> _ .... .. . <br /> . . ...� •••••�••• O i <br /> LEACHING LINE No. o' Lines Z/.. Length nr eo h line QO Total Lengi <br /> 'D' Box Type Filter Material. 14PISJL Depth Filter Material � ••• - <br /> ( Line <br /> Distance to nearest.Well ... .�. Foundation <br /> /.0 i-- ... Property <br /> ' . !�• <br /> SEEPAGE PIT ( j Depth Diameter Number Rock Filled Yes❑ No <br /> Water Table Depth. ...... . .. Rock Size... . ... . ... . ...... ................... <br /> ... .. . ... . ..... . ... . . <br /> Distance to neoresh Well Foundation Prop. Line - <br /> REPAIR/ADDITION (Prev, Sanitation Permit At Date <br /> Septic Tank (Specify Requirements) .... •' • . <br /> Disposal Field (Specify Requirements) <br /> ;Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaauln Cour"/ <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: <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 as <br /> to become subject to Werkman's Compensation laws of C0lifomI0-" <br /> Signed OwnK C` _'�- • <br /> Tit <br /> By ccc//yyylll <br /> f ther than owner) <br /> FORj4PARTMENT USE ONLY - <br /> -- — -------`� .e-.�.�... �f. --DATE <br /> APPLICATION Ao:.:EPTED BY (V/ DATE <br /> DIVISION OF LAND NUMBER <br /> ADDITIONAL COMMENTS EXHIBIT B 1 Of 2 <br /> �� �_�.., , Dote <br /> Final Inspection by. - y r ru 21e77 s[v rI„ P <br /> ,., 11A111111 1rnrAl u17AITH DISTRIrT <br />