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FOR OFFICE USE. <br /> APPLICATJ4 DN FOR SANITATION PERMIT FOR OFFICE USE: <br /> --------------------- <br /> (Complete in Triplicate) Permit No..7�+ © <br /> ----------------------- ------------------------ This Permit Expires ] Year From Date Issued Date Issued_$r..` <br /> Application is hereby'macle to the Son Joaquin Local Health District for a permit to construct and install the work herein described.'` <br /> This application is made in=cof pliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION_...- <br /> - - - ------- ------- ------�---------- -- -CE NSUS ACT a TF <br /> Owner's Name _ ._ ' ._ ._8•j <br /> TRACT <br /> TT = <br /> Address--' <br /> `i cit <br /> 5'� - - <br /> Name_ � _ pp� /�'�- --- --------ZiP---------- <br /> Installat onswill serve: Resit'deice --� -------------------------- <br /> ---------'.. 3 Q <br /> - ------- ----- / <br /> License # _ ._ Phoneb� <br /> s � Apartmen H se.❑ .Commercial ❑ Trailer Court ❑ <br /> Motel s❑' ..Other.- <br /> __ Number.of bedraoms.______,-.--Garba a Grinder_.:--------Lot-------- ----- <br /> Number of living units:_.,:. <br /> 41 <br /> _.!/ �� / tt`� <br /> Water Supply: Public System and name-------------- -- -------- ------__-- <br /> M.. �. , ": - -- - -- _Private� f <br /> Character of soil to'a depth of 3 feet:: Sand,.❑ Silt ❑ Cla �� ' <br /> Add-be <br /> ❑ Peat❑ Sandy Loam'K .Clay Loam r <br /> 'Hardpan ❑ , Adobe ❑ Fill Material___- _I yes, type__'_------------- <br /> -------------- <br /> (Plot <br /> _______________" <br /> (Plot Ian showin " ' --- �- <br /> plan, , g ize of lot, location of system in relation to-wells, buildings,etc. must be placed on reverse side.) ` <br /> NEW INSTALLATIQN: "[No-septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT• [ ]~ SEPTIC TANK • / S— e r <br /> Size--------- -� -�--+�---�---- ------- -- ((// <br /> �o � � -_-- Liquid Depth-�-----_T__"r <br /> Capacity.// `TY -" --------- <br /> Material---- d.C -_9No. Compartments---------- "-.-- <br /> i +.Distance.to-nearest: Well.__.-___--__ "' <br /> ✓� - - --------- Foundation. ,_ <br /> LEACHING LINE ! t.. , --`-�---•--"--Prop:-Line- ------------------- <br /> No, <br /> of Lines._____,-----_-.- --.Length of each line--------------- <br /> _____.Qct <br /> ! ._- `i r - :. - Total Length l 0" <br /> i D' Box___ Type,'Filter NlateriaL_h, c.. <br /> t - � . .. .�• t �. � ,-.- ---- --Depth Filter Material---- �-Z - -----=- -- -- <br /> 'Distance to nearest: Well_-___.__.J r _-_ Foundation--- <br /> SEEPAGE <br /> _�! r— <br /> r - <br /> - Property Line_ , <br /> SEEPAGE PIT , . _, , _ ------------------ ----- <br /> --� Number ---------r------Rock Fillad Yes ❑ No ❑ <br /> j - <br /> P <br /> d <br /> --- =---- -- -- ,� --- -----.---'Rock :Sixe------------------ <br /> --------------------� " <br /> Water Table�Depthmeter-�----- '-,�- -------- ------ - <br /> i -------- <br /> r Distance to nearest: Well-:'-----'-------------------"--- Foundation---.}_..--------- __--- <br /> t f <br /> rop. Line <br /> REPAIR%ADDITION (Prev. Sanitation-Permit#__-.___-_______ _ <br /> - ---=--- --------------------------Date.d- -----------= <br /> Septic Tank [Specify Requirements):-___ __,__-"-. .__; " <br /> a -----------_ ----------------------------Field (Specify Requirements) --------------- ---- - -------------------------------- <br /> D -- <br /> ji - - ---- ------------ <br /> 1 --- 1 <br /> f .. - - - ------- - - <br /> �_ _ - <br /> --- -- --- ---- __ ___----------- <br /> -i <br /> L_ - ___- "__. _._ _-__ �___ 6 <br /> 1t' ,ti [Draw existing and required addition on reverse side} <br /> I hereby certify that-l•,have prepared this app)ication and that the work will be done .(n accordance with San Joaquin County. .: <br /> Ordinances, State Laws;`bndfRules•and Regulations of `the-4an'Joaquin Lai Health District�Home owner or licensed a ents <br /> signature certifies the following: a I tY �� g <br /> "I certify that in theT '^ 'f i ' 1 <br /> performance of the work far which this_,permit,'is issued, l shall not employ anperson in such manner as <br /> to become subject to _Workman's Xompensati.ori- y laws of Californip." <br /> Signed---------------- <br /> ----- <br /> -------------- <br /> -_ -- <br /> Ow11 <br /> n�e <br /> BY------- ----- , :. .--------------------._ '.. .T rJ:``'' . , <br /> :.: <br /> a • <br /> i - <br /> --------- <br /> x f thea than owner) `� - _ . <br /> FOR PARTMENT USE ONLY. <br /> APPLICATION ACCEP-TED BY :_-_----'•f --- Gam. <br /> _ y, ----- - <br /> �'. _ DATE.: _---:---------------------------- <br /> -------------- <br /> --. <br /> DIVISION C►F-LAND NUMBER.'_-;I .F--� - ---- ----- _ � - - - - -------- ------ <br /> 3 <br /> ADDITIONAL".COMMENTS_."' ._"'._-� '4 ---------------------- <br /> --------------- <br /> i t -------------------------- -- --- -- -- -- i <br /> '. -- - -- <br /> -------- --------------------- r, _ --- - -- ------- ----------- <br /> -- <br /> = - = <br /> �t a <br />-------------------' "�--------1 _�-- --- _1 <br /> __ <br /> �-- - <br /> z _ <br /> Final Inspection by-n!._.n..r' t�{J -� �; ir { ,... <br /> SAN�JDAQUIN'LOCAL HEALTH DISTRICT, Fos 21677 REV. 71746 3M < <br />