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7OR C-rFICE USE., APPUCATiON _ <br /> lo-. ........ �R SANITATION PEtL1V11T <br /> (Complete in Triplicate) Permit Na. -.Z..,�........ ' <br /> ..... .......,..•....... •------------- - ----..__ This Permit Expires 1 Year From Date Issued <br /> Date Issued -_-:_ 2E ' <br /> Application is hereby made to the Son Joaquin local Health District for a permit to construct and install the work herein <br /> descrieed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations, <br /> JOB ADDRESS/LOCATION .:(,1`!} ,!L,1!;C..,4y:..--.."-c"�-�...../c.. ... ..� �h d_.*Zr NSUS TRACT <br /> Owners Name / --•--......... -� <br /> ---. moi... -- •. .•Phone <br /> Address 47 �.f(.:.. .._._.... -•-•--• eery .���—..... _--------------------•-------- <br /> ContracTor s Name . <br /> -------...--....License ii.�,?�I"'• ,�.1.. Phone -----•. ................ <br /> Installation will servo- Residence Commercial QTraller Court Cl <br /> Motel ❑Other . /- _/,�1'_ l_. - �_ <br /> Number of living units:............ Number of bedrooms Garbage Grinder ............ Lot Size ..._...... <br /> Water Supply- Public System and name ---,...-,...------ ^-_-_—._.._._Private ❑ <br /> Character of soil to a depth of 3 feet_ Sand C Silt❑ Clay ❑ Peat[E�- Sandy Loam ❑ Clay Loam Q <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ 1f 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 /> NEIN INSTALLATION: (No septic tank 4o- seepage pit permitted if public sewer is available within 240 feet,) <br /> PACKAGE TREATMENT j J SEPTIC TANK I j Sim______ ......____.......................... liquid Depth .-------------.....--� <br /> Capacity -------------....... Type ........ Material-------••--•--- No. Cornpartrnents <br /> Distance to nearest: Well ......._..........---..-_._.Foundation ......._-----Y.. . Prop, line <br /> LEACHING LINE [ ] No. of lines ........................ <br /> Length of each line._-.-_--..-------- Total Length ------- <br /> •D' Box Type Filter Material -...Depth Filter Mgfwial ------—-------------------..------ <br /> Distance to nearest. Well ,-----___. Foundation ---------------- Props" Una •--......--�-----•-- <br /> SEEPAGE PiT [ I Depth .--------------_. Diameter ----------- --- Number ...._ --------- ------ Rock Filled Yes ❑ Na C1 <br /> Water Table Depth ------------------------- ------..._.Rock Size -------------_.------------ <br /> Distanc a to nearest: Well ..,...................._........_--Foundation --------- ------ Prop. Line <br /> R9PAIVADINTION(Prov. Sanitation Permit dt ._ ­.,._-_______________________ Date •-•--._.,..---------_---—} <br /> Septic Tank (Specify RegwremeMc 1 J� -...._.It .�.... �! �..-•_- - - - <br /> Disposal Field (Specify R ireme�t+ts} _.__....-•--•--._.._. ._._..._.� ..._..____.._......__ — . ..__�....__ <br /> ,� ._ :._ <br /> ewfe_'07 <br /> _-----------------_-----------_.--------,---- <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that I have pmostred this application and that the work wAl lse deee M accMdetw wills S� Jeeigris+ <br /> County Ordinances, State Laws, and Rules and Regulatlons of the San Joegeiri Leooi Health.District- Neste ewow W Delta' <br /> sed agents signoture Certifies the failowing_ <br /> 'i certify that in the performance of the wont for whicts this Pertntt is issued, I shall not employ any Persalt fe such srt tM <br /> 3s to become svbiect to Workman's Compensation laws of Caiifor»ia." <br /> Signede ........................................ .............•-•••-••--••••••--•--_,,.,..---- Owner <br /> rt;r _......_ ..••............. Title ........ ...... .----.........-•---...................... <br /> .=i� <br /> (If other rhon owrwir <br /> L, EQR DEPARTMENT USrc ONLY ' <br /> APPLICATION ACCcPTED BY.... _....... .... .....•----...... ._-•---..........------_._.. DATE/"'`"".... - ;...._...,. <br /> BUILDING PERMIT ISSUED .. ........ ----- -- .,..,_.................. ........ ...............--..---- .,DATE . . ,....... _...... ..... <br /> 1GIT;OVAL COMMENTS . . <br /> ........................ ..- ..._........• _ .:.. ....-• .._......._.... <br /> ..............�; : .._. ... . . .... ........................... .........I.........•.--_.... Da.e Jr J,I Tl....... --,..._---- <br /> Fina( Inspection by- ..,................. ,....._........----------•-----.......... <br /> r ' 2L ?rcv. _ -z;=�l ,C;•OUiri LOCAL HEALTH $f�, � <br />