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s ........ ... FOR OFFICE USE: ; <br /> APPLICATION MDR SANITATION PERMIT <br /> Permit No. ....... :- .: <br /> {Complete in Triplicate) .. <br /> ............:....... <br /> ................. .....°....._......._.......... This Permit Expires Dote Issuedes 7 Year From Dot* � - <br /> + i <br /> Application is hereby made to the San Joaquin Loco! Health District for a permit to construct and install the work herein r <br /> described. This application is made In compliance with County Ordinance No. 549 o d existing Rules and Regulations: <br /> JOB ADbRESS/LOCATIO s _ ... ..........M..I�'�...... ...... j......CENSUS TRACT .......................... <br /> Owner's Name ..._.. G;-�--- ----- ----- L__.... ....._..............,..........._ <br /> .. _.. .... ..�... hone <br /> .................................... <br /> Address PP�� ..... �=�.� f . ....... <br /> ----------- City ................. <br /> Contractor's NameX_demA&/1__, &41_s.license # � ir"1-��-- Phone <br /> installation will serve: Residence Apartment House fl Commercial flTraller Court 0 <br /> Motel ❑Other .............. .. <br /> Number-of-living units:_._.-__ Number of droo X:Garbage-Grinder __. �"tot Site <br /> F <br /> Water Supply: Public System and name ..._., . __ _.. ...�. ..._. <br /> ••-- .-............•..................-......................--•.Private ❑ <br /> Character of soil to a depth of 3-feet:,.,._Sand-0. _ Silt Q— Clay-0. Peat 0 Sandy loans.❑. 'Ciay Loam Q. <br /> I Hardpan ❑ Adobe Fill Material _.......... If yes,type ............... ............ ' <br /> (Pivot plan, showing size of lot, location of system,in relation to wells, buildings, etc. must be placed on reverse skis.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted-if-public sewer is available within 200 feet,l <br /> PACKAGE TREATMENT [ SEPTIC TANK PA90y- Liquid Depth _ 7. ..... .1" <br /> Y Capacityf.,,Z40-CAL Type 1�Materials 'No. Compartments -�` -- .--- <br /> 1 Distance to nearest: Well -: .:•_ Foundation .._ A.._..._.--.. Prop. Line ..5?�.._...............J <br /> LEACHING LINE No. of Lines ..._. ....._ 1 4 � <br /> ------���-Length of eachTi;ne...-•- .f ---.---- Total Length �- <br /> r�+" j 'D' Box . ---- Type Filter Material _ �.-Depth-Filter Material .._`f'rr................................ <br /> t f <br /> ©)stance to nearest: Well __�` '_... Foundation ./41.1. ........I...... Property tine .....4................ <br /> SEEPAGE PIT [X Depth ._ ZY-7---_.__ Diameter Number ------Z___..---------- Rock Filled Yes �,k No 0 <br /> Water Table Depth .. ...Rock Size r. <br /> Distance-to-nearest:-Well . .:.� .R .......Foundation .. t .-_----- Prop-iind ...................... <br /> REPAIR/ADDITION(Prev. Sanitation .Permit# ..........------------------------•......... Date .......................-_-........ <br /> -Septic.Jank..(Specify.Requirements) ..................... ......................... j..............................•-------._................ ...... ............. <br /> Disposal Field [Specify Requirementsi ........................ `•• --- :._..T......... <br /> ---------- -----------T. ........... <br /> . ....... <br /> N1.F k <br /> ----------------------- ------- <br /> •_•---------------•-----------------------------..--------------------------....____•-_--__---••-__---••-•__ __•___•___...................................__.__.......------.............................. <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 Joaquin <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or 11cen. <br /> sed agents 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 <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ....� ........... ---••-----_----------- •---•--- Owner <br /> By -------- CE, Title ----- .. <br /> j (If other than o ser) <br /> i FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY ------ - <br /> ------ -- •- - - ---------•------------ ----- -------......-------....... DATE .... ... --- 2- --•--.......- --------- <br /> BUILDINGPERMIT ISSUED -------- -------I-- -------------------------------------------------------------.-----------------------DATE .------------------------------ <br /> ADDITIONAL COMMENTS ---------- ------ ---------................. <br /> .... - <br /> -----------------------------------------•--••--__----- --------•-••--•• ----............................----.....- ................ ---•-•----- <br /> -- ....... • • ............ . . . . .. .7.- ------------ <br /> ----------------- ......-----•..-••---.........._......_-------.-.------•---------_--- ._..._.-.......-- .......... ....... ----- -ll.-.-... <br /> -- - 1 . <br /> Final Inspection icy: . ----------- -------------------•--....._.Date .... .. . <br /> EH <br /> 3 2!a 1-66 Rev. 5M SAN JOAQUIN 'LOCAL HEALTH DISTRICT 8/74 3M <br />