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APPLICATION FOR SANITATION PERMIT <br /> f compfeto in Triplicate) <br /> Permit No. ...7�:ZE <br /> - = ..--.... .............. <br /> Date Issued �� 7 6 <br /> ... This Permit Expires 1 Year from Date Issued ' ..-...`..... <br /> Application is hereby made to'ihe Son Joaquin Local Health District for a permit to constrict and Install the work herein <br /> described. Tfil;- applicatio_n_ Is made In compliance with County Ordinance No. 544 and existing-Rales and Regulations: <br /> j .JOB ADDRESSAOCATIO /�.� ....................„ -viva `ate 1...............cEi�fst�s BRACT .. � ...- <br /> Owner's Name ..: . . .----•-•--.. ...................................Phone .................................... <br /> Address ........... ;'i /� ilii. Gg/�....1 D................sty j moi• .� 0` ......................................... <br /> Contractor's Name`-`_ ....”. ... License# .��.lr. .. Phonwg�e�A� .. <br /> { <br /> Installation will servo► I Reildenoe❑Aparfn'ient`Hausefl Corinmerda![]Trager Corot <br /> t t,t! � Motel ❑Other 1 <br /> 2}_ Number of bedroo s_ 'Z J age Grinder ....:....... Loi --•----....•----....... <br /> f' Number of linin unitar:..' T i <br /> Water g� , a f r ..... ............... <br /> Supply: Public System and,nom .................................__....................—.-.---._...................-.........-. ......Private <br /> i Character of soil to a depth of-Ueet: Sand 0 $lit <br /> Q Clay_❑ Peat❑ Sandy Loam W day Loom ❑ <br /> Hardpan❑—Adobe-❑`"fill Matorlal ............if yos.tyle........................... <br /> -Plot plan, shawind size of lot, location of system In relation to wells, buildings, etc, must be placed an reverse side.) <br /> NEW INSTALLATION:i (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) `l <br /> PACKAGE TREATMENT { ] SEPTIC TANK ] ... <br /> Size .. ..�.1�-� Liquid Depth . ............... <br /> Capacity ,' .... Type s..�'E".Z. Material...................... No. Compartments ...................... <br /> Distance to_nearest, Well Foundation ................-� <br /> _ ............ Prop. LineZ .�LEACHING LINE LINE A [ ]—,- No. of Lines ..............._. LengthWofeach line..., . . �............ Total Length <br /> 'D' Box .-. ....._ Type Filter Material Filter Material �, �� I ...........® <br /> ! <br /> Distance'to nearest: Well ......................:Faundatlbn . . Property Line • ........................ 1 <br /> SEEPAGE PIT { ] Depth 4.' ; :. Diameter ................ Number . . ........ • Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ............................. <br /> --............ <br /> ..... <br /> Rock Site ................................ V <br /> { 'Distance to nearest: Well ........................................Foundation .................... Prop. Line ....... <br /> REPAIRlADDITION IPrev. Sanitation Permit qP ............................................ Date ...................................] ..». a....� <br /> Septic Tank (Specify Requirements) -...-•-•................................. ......................................_...................._...»..._...._....... ... <br /> Disposal Field (Specify Requirements) .......................................................................................................................................0 <br /> IDraw 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 ateordance with Sam Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Ham* owner or 11011- <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 toy any person In such manner <br /> as to become subject t o n's o pensallon laws of California." �.� <br /> Signed <br /> • Owner <br /> ............ ..................................... <br /> By .. ................................................. title .................._. <br /> Jif other than owner) <br /> FOI DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br />' BUILDING PERMIT ISSUED ......T. <br /> . .. ......................COMMENTS ...... ..........:.. <br /> _. <br /> ---------- <br /> Final Inspection by: .....-.. ........................_...•.Date .. - ,ji_- ..-...-.--.... <br /> EV <br /> 13 2� �"�' IL°v• t SAN JOAQUIN L L HEALTH DISTRICT 8/7h 3A4 <br />