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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION rERMIT Permit !Co .. �/47 <br /> _.. <br /> ......1...... <br /> (complete in Triplicate) 7y <br /> ........ . -- _1111 <br /> ..................... <br /> Date Issue"'-�- <br /> ......... . ....:..............-.............. .._1 111. <br /> This Permit Expires i Year from Date issue <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work �n <br /> described.This application is made in compliance with County Ordinonc ' No. 549 and existing Rules and Repviationss! <br /> .....CENSUS TRACT 1111..-... <br /> JOB ADDRESS/LOCATI N <br /> . ........ .... <br /> .... �.,�..... <br /> Owner's Name ...... ..0 .. 01 <br /> /r2. ............City y �. .. ..._......,r...- <br /> dress / ?.'. Phone <br /> Ad <br /> d•�. .. <br /> 1i <br /> Contractor's Nome .. `� <br /> r `�``"" ' <br /> installation will server Residence Apartment House(] Commercial QTraller Court <br /> a Motel❑Other ............................................ Lot Size <br /> Number of living unffsr..... <br /> f.... Number of bedrooms o5.......Garbage Grinder ..... ...... ..........Private <br /> Water SupplyE Public System and name ....................... .. Cla Pool[] Sandy Loom j� ay Loam 0 <br /> depth of 3 feet, Sand j] Silt❑ y ❑ q, <br /> CFiarocter of soil too cep � <br /> r. Hardpan Q Adobe❑ Fill Material ............If yes,type.:....... <br /> ......... <br /> ....... <br /> :.. <br /> t be <br /> amd On <br /> {Piot plan, showing sixe of lot, I:>catian of system in rotation ro wells. buildings. stc. ��within��A feet.) �� �� ;r <br /> N`EVIf INSTALLATION (No septic tank or see go pit permitted If bllc sewer is ave ,S <br /> 1. �� 1111... Liquid Depth ...T..... <br /> :..�...--- <br /> SEPTIC TANK Sly . <br /> PACKAGE TREATMENT ( ] �-- <br /> CapocityL20ef. Type .. Material.. t+« -� No. j(,otmpartrnetth 1 <br /> to near <br /> art. .......... '�.!................Foundotitxt....,..�..........prop.Uro'•• --Distance Tf'.. Yawl Length <br /> LEACHING LiNE (� No. of lines ........., ........... Lsnpth of each line...... " MateHal .. . ,•• ,. ._...� <br /> T Filter Materlai ..... ......Q°pth Filter S' A <br /> 'p Box ....1....... Type i ......,.... Property ue►e 1 <br /> Distance toaanearosts Well ....:.r�'.......... at on Itack Filled Yes ���C3' <br /> Depth ....0.. ,... ttll�R.��d.l..�... Number .......... ..� .. .^... <br /> b � ..Rock Sire ....�..1., •• i <br /> Water Table Depth .............. ��, i gip. Line ..r'`� ,�• <br /> � Distance to nearesh Well ........... .., .. 1111 �.:.. <br /> REPAIR/ADDITION(Prov. Sanitation Permit 40 ...................................... <br /> 1111.. Dole ..............................'1111.. 1111......._......: _.... <br /> Septic Tank(specify Requirements) ....:.............._.........................................,,.,.........:.....^ ..............................I.. .............. <br /> Disposal Field iSpecify Requirements) .................................................................... ...... <br /> ........... <br /> .......11.1.1........ <br /> ...•Ipraw existing and required addition on reverses a with Son <br /> ii hereby certify that I haw prepared this application and that rho work will 6o done In aocerdama <br /> County Ordinances Pilate Laws, and Rules and Regulations of the San Joaquin local 14611h Dlsteld•Home•caner Wgess• <br /> !sod agents signature certifies the followingsM suds rNemew <br /> S <br /> ' certify that in the performance of the work for which this permit is Issued. 1 shall fret employ arty Pers°~ <br /> as to become subject to Workmen's Compensation laws of Callfwnla," <br /> `Signed ......... ................. .... .. -.1. ..:....T. .. . :�`� ... <br /> !Signed <br /> Owner .tf{ !......... ............................ <br /> .. <br /> .s.... ��L..... Title ..� � <br /> t ilf other than o mer) <br /> FOR pEPARTM1iNT USE ONLY <br /> l �APPLICATION ACCEPTED BYG .....................................................1.......1.......11.. <br /> ZVI <br /> ........ DATE ..../. . . ...... <br /> ...........DATE .....................�...........__1111. <br /> BUILDINGPERMIT ISSUED ................................................................_...........................,......._......................................................- <br /> ADDITIONALCOMMENTS........................................................... .............................................. ........................ .......... ...... ........ <br /> ..... ................................... ...............................Date ....f .� .���-.._....... <br /> spa io .........��........................................ .............. <br /> • i`Final Inspection bye ..........:. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> a s 7/7251 <br /> 13 z4 <br /> E.N, 1--68 Rev. 5M ' <br />