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FOR OFFICE USE- <br /> ......1-............. .......... ......... APPLICATION FOR SANITATION PERMIT <br /> ..........­....................... ........ ........... lCompleto in Triplicate) Permit No. <br /> .............I. .._. ... . . <br /> This Permit Expire Date Issued ...... <br /> s I Year From Date Issued <br /> Application <br /> pp" a'on is hereby made to the Son Joaquin Local Health District for 0 Permit to construct and Install the work heroin <br /> described. This application Is mod'o,in,compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION _y_74Q... .......­­............ ..........,.CENSUS TRACT ................. <br /> Owner's Name <br /> ..Phone <br /> . ........ city ............ <br /> Contractor's Nome ........... ........... -------- <br /> rIre'IV ?er<,4 2 <br /> Address eV mv------JU--- <br /> on <br /> -V.................License # c;27,fs;. <br /> V601 one -4.11W <br /> Installation will serve: 61,�.,.47 ph <br /> Residence 0 Apartment House 0 Commercial OTraller Court 0 <br /> Motel 10 Other <br /> Number of living units._4---- Number of bedrolomsGarbage Grinder .......... . Lot Size <br /> .......... <br /> ;5 ....... <br /> Water Supply: Public System and name ------- <br /> t . "V--------*.......................*.............. ....................... ...........Private 1@0 <br /> Character,of sail to a-depth-dif 3 feet. Sand <br /> U�JS'lt 0 Clay El Peat 0 Sandy Loam Clay Loom [J <br /> Hardpan 0 Adobe 0 Fill Mcteriaf <br /> .... <br /> ............... ............ <br /> (Plot Plan, shoZ'ingi size of-jot, location of <br /> system in relation to wells, builil?198, etc, must be placed on reverse side.) <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer.is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK <br /> Size...- 'l_0. ....... Liquid Depth ........................... <br /> Capacity-o--- ---- <br /> -- Type No. Compartments .6................ <br /> Distance to nearest. Well <br /> ............ ---------Foundation .............. Prop. Line .3/0............ <br /> ...... Length of each line-- .............. Total Length ........ <br /> LEACHING LINE No. of Lines <br /> '13"Box .../....- Type Filter Material t. _.Depth Filter Material <br /> 4 <br /> Distance to nearest: Well ..... ..... Foundation 454 .............. Property Line <br /> th' f <br /> SEEPAGE PIT Dep Diameter <br /> Number ......49.......0........... Rock Holed Yesja No ChK <br /> Water,16Wb�Depth .............­­......... ---------............Rock Size <br /> t6nearest: Will ..._I <br /> ..........•..............Foundation Prop. Line .............. <br /> REPAIR/ADDITION(Prov. Sanitation Permit-# :......._....-•.-- <br /> ......... Date ...................... <br /> Septic Tank (Specify Requirements ....... .................'r <br /> ................................................. ........................................ <br /> Disposal Field (Spec fey, Requiretff-entsi ---- - <br /> ------------------------------------------------ ------------------------------------------------------------- <br /> ------------ ............... <br /> ------------ ............... ........ ........... ....... ------- ....................... <br /> ---------- ------------ --------------- ............................. <br /> ------------------------------------- <br /> ---------------------•----- <br /> *--------------- ......*--------- ---------------*------*�­'­........ <br /> (Draw existing and requ ar4addition on reverse side) <br /> I hereby certify that I have prep6rod.,this application and th0' � <br /> d . t We work will be-done In accordance with San Joaqu'ln i <br /> County Ordinances, State Laws, and eules-and Regulations-of the Son Joaquin Local Health,,District. Nome owner or Ilcon- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work f6ir—which this Permit is Issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Comports fionIaws of California." <br /> Signed --------- <br /> ------ - ------ -------- <br /> Owner <br /> BY -------- <br /> ---------------- .. ........... -------------------------------- Title ........(if other than ownerl <br /> ........ ............--------------------------- <br /> FOR <br /> ............ .............F0 DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- -- ---- <br /> BUILDING PERMIT ISSUED .. ..... .... ------ ------------- -------------------­­------------------------------------- DATE <br /> -- -- <br /> - .. --- --- ------------------------- <br /> ADDITIONAL COMMENTS ----- _1 ------- ........... ------- -------------------• --------------- --------------DATE ...... ..................... ............ <br /> ............I .......------••-•-- ..........)e,;Aj........... <br /> t---- <br />- ---------- ------ <--"/-------- ............... .............................. ............ <br /> ........ ........... ........... -./ - <br /> _0 51/7 <br /> Final Inspection'h .X. M&------------------------------------•----•--......--•-.: -------_ ----•- ---------- I-W........................ <br /> .................. ...... .....................Date ...... Ju <br /> ... ....... <br /> EH 13 2h 1-6 V. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7. .....3M..C-(5­ <br />