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PGR OFFICE USE: AMICATION FOR SANITATION PERMIT <br />:..., ��. .... .......:...:.:::.....:.......... tComplebin Triplicate) Permit No—, aZI <br /> ............... .... .. ....................... This Permit Expires t Year from Date Issued Date Issued . a...�"74 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliancew4th County Ordinance N 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA ;... ............:.. ._. �._.. ...... . . ...CEP "US TRACT ._.................. . <br /> Owner's Name ........ .# .....0 _. . ..L... .. . .. ....... . ......................................... .:....:..:............. <br /> Address ............. J�........ _...... ...... ... ...... .--....:City . ........................-----•------ .----..... <br /> .. <br /> Contractor's Name --- ._....` ..... ....... �.�' .:.--•----... .....Lkense� h Phone ' �6p. <br /> Installation will serve. Residence Apartment fie -is fl Commercial)]Traller Court Ej <br /> Motel Q Other_...__.. :..._.... <br /> Number of living units•...:C/ Number of bedrooms d»...taarbatge Grinder ...._..:.... Lot Size <br /> Water Supply: Public System and name ............. ......_ _ .._.............---...._.........._.........1'rfvate <br /> Character of sail to a depth of 3 feet: Sand 13 Silt C1 Clay 0 Peat Q Sandy Loam C3 Clay Loam <br /> Hardpan�Adobe at_Fill Material.......,.... 1#yes,type............... .......»... <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on revere slde.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if qublic sews is available within 200 feet,) ` <br /> PACKAGE TRFATMENT [ ] SEPTIC TANK .0 .. ..................... <br /> .. . ............. Liquid .Depth z. <br /> .�..,. Capacity lP-0........ Type ---......... <br /> . Material k�. No. Compartments .......�.t-...... " <br /> Distance.to nearest: Well . ©�....._..--.•--•-.....Foundation .....1.�_.......... Prop. Line_...�C. .... <br /> LEACHING LINE [}� No. of Lines . ........... -..a.......,... Tata! Length .....». <br /> 'D' Box ..... Type Filter Material . ..Depth Fitter Material .t <br /> .�- r <br /> Distance to nearest; Well 4.16-1•-.-_-.... Foundation ........1 Q ... Property Line .....� .......,... <br /> SEEPAGE PIT ( Depth ..-L-4-f. Diameter .n a .r/ Number -_I..........�.... Rock Fill Yes fig, No <br /> EVE-.11W <br /> t i <br /> Water fable Depth .`............................. <br /> -•............... RockSize .........�.............. -- - �' ,. <br /> oDistance to nearest: Well ....I.,��.......................Foundation Prop. Liras n51.._. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ...................................l <br /> Septic Tank (Specify Requirements). <br /> -----------------------------------.................................................................................... <br /> ...._. <br /> Disposal Field (Specify Requirements) -- ...................................................................................................................... <br /> ...».,:.1 <br /> -- ---- -- - - . <br /> .....................•--•-- --------------------------- - --------------------------------------------- ...._._. ........... -- ....--......... .. <br /> ...........----.. ........... ...........•-• <br /> (Draw existing and required addition on reverse sidel <br /> I hereby certify that 1 have prepared this application and that lite work will be doge in accordance with San Ja"Vin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,,District. Home owner or Ilcoa- <br /> sed agents signature certifies the following: _ 1 <br /> "I certify that in the perform"co <br /> of the work for which this permit is Issued, I shall not employ any person in such manner <br /> as to become sub ect t r m n Compensa on laws f California." <br /> Signed ----------- -- --�----�----- - -.`3-:-�------ _ _ •----- - <br /> BY .._ Title ... { <br /> (If other than owner) Ar 4 <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---•--•---•------ ------•--------...-.-....._--...-•------------.. DATE -- ...........L <br /> BUILDINGPERMIT ISSUED ........................• ..... --- ------........--..........---.---•--.............._..................DATE ----------....----........... <br /> ------------- <br /> ADDITIONAL COMMENTS �.............•-• <br /> ----------•--••- ------------------------------------•--•--- - ------------.-------------------------.............................. --------...-. -.. <br /> -------------•-- --........... . ...... .. --•-- -------------.--- -----•-•-•- •-----...-------•-•..... <br /> ................. . <br /> Final Inspection by: ........... .. Date .. p. .- --.- . -- <br /> ----------------- -----• ! �! ---- -----------------•---- <br /> EH <br /> 3 2tt 1-d13 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7!i 3M <br />