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r7;ly FOR OFFICE USE: <br /> OFFICE USE: ppLICA-1ION FOR SANITATION PERMIT Permit No-V-"•'�5.71 <br /> ............ in Triplicate) 4p l5%> <br /> ..... --- ----­--------- Date issued------ ------- <br /> ............ ----_--------- ...... ......... d <br /> )This permit ExpirW1"year From Date Issue <br /> ......... ....................... <br /> ........... construct and install the work herein described. <br /> a to the San Joaquin Local Health District for a permit to <br /> Application is hereby mod 49 and existing Rules and Regulations.. <br /> in compliance with County Ordinance No. 5 <br /> This application is made.i <br /> ...-.CENSUS TRACT-------------- ------------ <br /> ..... ........................ <br /> . ..... Phone.. <br /> JOB ADDRESS/LOCA I r ------- <br /> . . ...........L........... <br /> ............ . ....................... <br /> ............... <br /> s Narne-'.. <br /> Owner's <br /> ---------- <br /> -S, .9 <br /> . ... . ... Phone__W4 <br /> ............. . ..... <br /> Address_.- cense <br /> Li <br /> -..1—.............. <br /> Contractors Name___...- _�A Court El <br /> Co eQ Commercia 7 <br /> anc IN <br /> IV4 <br /> serve: Re e �artment HOUS <br /> Installation ��111 se ........ <br /> . ........ <br /> size._ - <br /> _.Gorbqge-Grinde(­- <br /> wr of bedrooms ------- Pri�4ate <br /> Nu` ber of living: -u its:._:. ......... <br /> Number ... ............ <br /> Number <br /> ............ ...... <br /> ............... ............� <br /> Water Supply. Public§.ystem and-name..., clay Loom <br /> ❑ ndy LOOM <br /> so <br /> Peat <br /> ---------- .........;-• <br /> ----- <br /> e0th of 3 feet- Sand Ll !Silt El Clay El <br /> 0�soil to a depth Fill Material._Ha dean-[ _.-:.__._.If yes, <br /> n reverse side-.)--- <br /> tc.'must be placed 0 <br /> relation to-wells b6ildings,'e <br /> 1§f,;m i n jtKih, feet,11 _o.,- <br /> 'i-size of lot, 16�cltic`n off-sy cii[oble,w 2 <br /> (Plot plain, showih d if 0 1- q_111 <br /> septic tank :or seepage pi permitted of vc��,�. _�-_(%#� <br /> -.kw� t er is av <br /> (Njc�. . -1 nitte tjquTT.Depth.._ ."5__, <br /> NEW-INSTALLATION':' % <br /> SIZ ------ <br /> SEPTICTANK <br /> PACKAGE TREATMENT'.-[ ] ------ o__C_a�nportrne1nts ------ <br /> .... ...... <br /> Capacity_A;?�O=�NT_yp .4e <br /> ry• i� ation--- <br /> ............,�Founcl <br /> !r • o_nede�st- Wel Lengthl-_­_ <br /> zistdnce4rI <br /> At Total! <br /> Length of each line.-Vi <br /> _,Len� <br /> ..............i;;:j <br /> R o <br /> of Lines�� .......... <br /> H NG LINE e Fitter Material------ <br /> 1Z, A�C <br /> K Type --------------- <br /> .110: Filter.h '01 ..... <br /> Line. , <br /> _;D No <br /> Distan to near. ...... led Yes' <br /> ce% �st: Well I Rock Fit <br /> �T ......... <br /> E` <br /> __F 11%. -Y .......... <br /> _5----Diameter_ . : <br /> SEEPAGE P1 if . , . , . -------- <br /> PAG ock Size <br /> R <br /> ............ ...... ..... .... <br /> -------- a L ne .5� <br /> ldv <br /> Water P. 'i -- ------ ------ <br /> to n.earest.,Well------------- -- -------------­ .......F <br /> Distance: I . . %-. ............ <br /> D to.............r...:.t <br /> REPAIR/ADDITION (Prey.-Sanitation Permit#--•==---=-"•---:------ ...... ---- ......­­ <br /> ------------------------ ...................... ...................................... <br /> Septic Tank (Specify ..................... <br /> ...................... <br /> (Specify Riec <br /> Disposal Field'(S . ............... <br /> wr <br /> ................. <br /> ----------------- <br /> ..............................!;- ........................... . ............... . <br /> .......... <br /> ................ <br /> ................................. . ....... ......... ed 'ddition.on reverse side) <br /> (Draw existing and requir a Son Joaquin County <br /> and that the work VAII be -done in accordancet-wl licensed agents <br /> I hereby certify that have prepared this,aPPHc0f1on a istrict. Home owner or fic <br /> Laws, and RV:Ies.and Regulations of the Son Joaquin Loccil,Heallth D <br /> Ordinances,' State <br /> following: 'in such manner as <br /> signature certifies*Ae'f* . I .ed, shall not'iwmPlcy any person <br /> "work f6r which this permit Is issued,"ll certify that in the cier!`66�:anci of-the <br /> Man's Compensation laws of California <br /> to-become -Owner <br /> IC, <br /> Signe --------- ------ --- ------ -------- <br /> Titl <br /> ........... <br /> r <br /> By. <br /> at er <br /> (I other on:ownerI <br /> 'MENT USE ONLY <br /> DEPARI <br /> D AT�' <br /> ......................... .......................­­ -----I ...................... <br /> APPLICATION ACCEPTED ------------- --- . ..................r.........DATE... <br /> PP ...................... ...................... <br /> DIVISION OF LAND NUMBER------------------------­---- ---------- ............. ........... <br /> IV .................1---------------­ ............... - -------------*......... .................. <br /> ADDITIONAL COMMENTS--------------- ------------:............-----------------------------------------------:*...*----------------------------------- <br /> ...._*................._--------- ........ ------------------ ......... <br /> .................................... . ....... ................ .................... ------ - - ................................. <br /> ............. ...... <br /> ......................... ........... .......... ............ .................................. ........:7- <br /> _11---------------- ------- --- >............... <br /> .......... -------------------------- <br /> F&S 21677 RrI6 7�176 3 M <br /> Final Inspection by--_-_--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EN <br />