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FOR OFFICE L-JSE.- 1,30 APPLICATION FOR SANITATION PERMIT <br /> ..I V Permit No:. <br /> ----------:---- ---------------------- -(ccriiplifii in—Tei liccifell <br /> R/I/M 17W . t, P <br /> 1----------- - d 11 <br /> ------------- --------------------- DateIs.ued -------- ---C----9 <br /> -- -------------------------------------- <br /> -------------- <br /> -- This Permit Expires I Year From Date Issue <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made.'in compliance with County Ordinance No. 549 and existing Rules and Regulations- <br /> ---t571--- CENSUS TRACT --------- --------- <br /> JOB ADDRESS/LOCATION .-/­­/` ­­­g?�0--. --- ---------- -------------------- Phone -----------------------•------------- <br /> >16--, 7 --------------�-; ;`­ i <br /> Owner's Narne - ---------- <br /> ----------------------------I City <br /> 774f------------------- ---------- <br /> Address --------- ------(S�5- sr <br /> -------.License Phone�� <br /> Contractor's Name ------ <br /> Installation will serve: Residence Apartment House,E] Commercial ❑Trailer Court <br /> Motel [] other ---------------------------------------- <br /> pfI <br /> W s Grinder <br /> Lot Size -7A-X --- ---------- <br /> Number of living units:---/----- Number of bedroom I-------Garloct-ge Grini <br /> _Jjj:!� -----Private El <br /> wate'r,Supply: Public System and n <br /> Silt El cl oy E:] Peat.El tSondy toom ,E] Clay Loam,[] <br /> Character of soil to a depth of 3 feet: Sand'E] <br /> II-Moterial ----------- --if yes,type ------------------ - <br /> Hard an E] Adobe Z�_Ifl <br /> Aj <br /> 'jot,locati6n of system in relation to wells; buildings, -etc. must be placed o6 reverse <br /> side.} <br /> (Plot;plan, showing size of #� X�j '"' <br /> NEW INSTALLATION* (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> t <br /> Size---- Dep'tV------------------ ------- <br /> T' NK'[ ------ ----------- — i <br /> PACKAGE TREATMENT SEPTIC A .1 I ---- ---------- <br /> No. Compartments <br /> Capacity -------I-------------------------- Type -------------------- Material.--------------------- <br /> ---------------- Prop. Line ----------------------- <br /> Distance to nearest. Well ------------------------------------Foundation ------ I <br /> I <br /> LEACHING LINE No. of Lines . ..... ........ Length 6 , __;�----­---- <br /> ------- Length of each- line.-__._---------------------------- Total Leng -------------- <br /> .. . . <br /> - <br /> 'D' Box pe Filter Material --------------------Depth Filter Material ------------------- ------ ---------- <br /> -------- Ty <br /> Lines ------------ <br /> lo nearest: Well ------------------------ Foundation ------------------------ Property 1, <br /> a Distance ❑ <br /> No 0 <br /> SEEPAGE PIT Depth ---------- Diameter ---------------- Number ---------------------------- Rock Filllt�lyes <br /> ------------------------------- <br /> Water Table Depth -------------------------------------------------Rock Size <br /> 'Line -------_------------ <br /> Distance to nearest: Welt ----------------------------------------Foundation ------ ------ Prop. <br /> Permit# ----------------------------------- --- Date -------------=--- <br /> f -------------------) <br /> REPAIR/ADDITION(Prev. Sanitation <br /> Disposal Field (SpecifyRe -------- <br /> Septic Tank (Specify Requirements) ------ -- <br /> ---- ------ ------- <br /> -----------4�p- <br /> rem ntr, <br /> . quit,) <br /> ---- ---------------------------------- <br /> ------------------------ <br /> ----------- ---------------- ----------------------------------------- <br /> ------- --- <br /> ---------I ---------------- ---------------------------Draw existing and required a_j�ition-on_rev_e_rse_s`!_d_e_) 'w.ith Son Joaquin <br /> F application and that the work N�ill'be done in accordance i <br /> I heriby certify that I have prepared this OPP or or licen- <br /> Couniy Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Loc�cif'Heallh District. Home owner <br /> wn <br /> sed agents signature certifies the following- <br /> of the work for which this permit is issued,'11-shall not employ any person in such manner <br /> "I certify that in the performance - 11 <br /> as to become subject to Workman's ensation laws of California." 4 <br /> Owner <br /> Signed ---------- ------ ----------------------------- ------ -------------------- --------L <br /> ---------------- <br /> By ....I------------ --- - ------ Title _. 7 <br /> ------- <br /> at er than owne <br /> FOR DEPA*TMiNT USE ONLY <br /> C <br /> DATE -----N -- ----- <br /> kman's CoLo ens, <br /> Signed --- ---- ---- ----- <br /> ---- - ------ <br /> y I at er than <br /> BY ---- <br /> owne <br /> PPLI - - ----------- - ------- --------- <br /> APPLICA ION ACCEPTED BY - --- -------------------- <br /> ADATE --------- <br /> BUILDING PERMIT ISSUED ------------------------------------------- ........ ---- -- <br /> ----------- ------------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------ ---------------------- -------- ------------------------ --- <br /> ----------------------------- ------------------ ----------------------------------------- <br /> ------------------------------------------------------------------ ------ ----------------- --------------- <br /> - --- --- <br /> --------I ------- ------------------------------------ <br /> ----------- -------------------------------- ------------------------ <br /> ---------------------­­------------------ <br /> ---- --------Date <br /> ------- -----­--------------------- ep <br /> Final Inspection by. -------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M, X\ x iA � <br />