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x <br /> FOR'OFFICE'"USE: ° FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (CVomplete in Triplicate} Permit No._Z�77.0'01F <br /> /le ,�uJcLL�.rte C <br /> --------------- This Permit Expires 1 Year From Date Issued Date Issued---.-----_" -� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordina ce No. 549 and existing'Rules and Regulations: <br /> - F !JOB ADDRESSAOCATI - <br /> -- -----EY-/--~-- <br /> - f-- ,.. <br /> . - <br /> RA--C- <br /> T_ <br /> - _CEN T <br /> Owner's Na , v-�k_ ---- - ---- PhonepAddress....7L -01 --------------- -- . . <br /> re� Phone--------- -- --- -LicenseContractor's Name <br /> - <br /> ---------- ------ ------- <br /> Installation will serve: Residen ek Apartment House.❑ .Commercial 0 Trailer Court ❑ <br /> Motel <br /> ' t ❑ Other = "-------_--'= =---i----- <br /> Number of living units:---'- -___.Number.of be ooms:_-_ arba9e Grindert-Lot.Size_-___ <br /> ----------- ------------- <br /> W <br /> aiter Supply: Public System arad name______._ <br /> ---- -------------------- ---------Private <br /> Character of soil to a depth of 3,1eet: Sand Silt❑ :Clay❑ f Peat[] Sandy Loam ❑ Clay Loam <br /> l Hardpan ❑ Adobe ,Fill Material_-.. If yes, type___! __________ <br /> (Plot plan, showing size of lot, lova#ion of sys-tem elation to wells, buildings,"etc.1must beplaced on reverse side.[ 6 <br /> NEW INSTALLATIONe .[No septic tank -or seepage ..pit permitted if public sewer is available within 200 feet,] r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK i�� 4 Size-- ~ r ('' ( __ <br /> ---- --- - --------------------------Liquid Depth <br /> ff - YPr <br /> : <br /> Capaat Q ,T e G .Material- --- --[ o. Co impartments-___.1-------------------- <br /> 1 <br /> LEADistance to nearest: W --,------Pro Line___ '-- <br /> f <br /> CHING LINE xJ <br /> No. of L}nes_---- I _-----_.Lei th f each line.- - 1,-_ - a <br /> ' s ri;: > 11- 9 rQ Total Length.. <br /> D' Box--?l__-Type Filter Mat�r�drl-.- f <br /> L <br /> -_ Depth Filter Materia€__-_ <br /> >. Distance tt ----f------i------ --- <br /> o nearest: Well_'_ ----ou - _ 7 ' r <br /> • � Well-;- - ----------- <br /> � ---- _ F p ty Line -r-J----� ----- <br /> ---- ------- <br /> �. ._ ,,, .. I t . .. . .F n at __ -Q-- <br /> `SEEPAGE PIT Depth- f Diam#teer-:----___ _ f r ion Pro er <br /> o -s ' --- Number--- a— -- -- Rock Filled" Yes Na ❑ <br /> i t :.... T.. .. r <br /> Water Table Depth--- - � ---------`-------=-----Rock ;Size_._-p_ - --ry------------ i. <br /> Distanceito'nearest: Well._ _ 0 Foundation__-_- f <br /> ��--- ----"Prop. <br /> �,..ate' -k �: ..`��.a +�..- ...d•-r--r.�r�.� � <br /> O•fREPAIR/ADDITION [Prey:Sanitation.Permit#-3________________ <br /> I <br /> Date : ------ ) <br /> Septic Tank {Specify Requirements]- .,- ------------------------------ ------- <br /> ---- <br /> a k <br /> D sposal Field (Specify Requirements) - -- --------- ° - - <br /> --------------------------- <br /> ' <br /> 'z� .... -- <br /> - <br /> �' } <br /> T _ _ _ <br /> hereb certif •that I have re ared thpra rination and that the`worlkwill�be�d r- I <br /> rse side) . s <br /> y y -prepared PIS one in ordance with San Joaquin County <br /> Ordinances, State Laws, and Rules -Regulations-of4the-San-Joaquin Local gilt' ,District/Home owner or licensed agents <br /> signature certifies the following: 1. <br /> "I cern that'in"the r l I <br /> certify performance of"the work for-inrhich this permit,is issued,'] shall not employ any person in such manner:as �� <br /> to become subject to Workman s Co_ m ensation�laws.of-Californici .� 1 <br /> I P _ <br /> Signed-_-_-- ------------- ---- - t C►wnea CERREhiC SEPTIC SEWER SER1lll;9 <br /> ES t <br /> ;:-. : ------------ Z&3 So bto` -t Stbcktbn Calif: 9524 • <br /> BY_ - .. <br /> 1 -- '- T1tle_-- : P_ii..463-32D1 =':-Contractrr'sLic.#. 61 -_-- <br /> (If other than:owla&) I . . . <br /> `i O� DEPARTMEN_T`l� E-ONLY � <br /> APPLICATION ACCEPTED BY----- ` �` a " <br /> ! ► ---------------------------------------' E� <br /> DIVISION OF LAND NUMBER__________________ f 7 <br /> �r # . f €.^fit 1 <br /> ------ ----------- <br /> . . �..� _ -.DATE.----------- --------------------- -'--- <br /> ADDITIONAL COMMENTS --- ` <br /> ` ! <br /> = - <br /> 4 / i-��rd # , ,. <br /> f r — <br /> --------------- <br /> ---------- �l <br /> - ----- <br /> , <br /> nalInspeetio� bFia <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 677 REV. 7176 3M <br />