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T <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERS MP-0- <br /> Permit No. ---- --------------- <br /> ................ ------.................. (Campleto in Triplicate) <br /> Date issued ............ <br /> ...................... ........ I <br /> This Permit Expires 1 Year From Date Issued <br /> A-pplic h y e-to the Jim Joaquin Local He*alth District for a permit to construct and install the work-hetelh <br /> is application is madeln compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> described. Th <br /> I - - - I #,- 11 Ro>_o tv.-CENSLIS TRACT --- __- ------ <br /> JOB ADDRESS/LOCATION _L�. ...... Y.v <br /> Owner's Name . .......W.-,.wg� ....... ___..................Phone ------------­-­----- --------- <br /> -74CJ 0 ----------- <br /> ....City ........ <br /> Address .......... ------- -—------------------------------------------ 6 Phone _.57 a 3 <br /> Contractor's Name --- -ty--- ------ ........License # IX47_47e ---------------- <br /> HouseO CommercialxTrailer Court 0 <br /> Installation will serve: Residence 0 Apartment <br /> Motel M Other -ADMiAlT---dFE1.CF_. <br /> ....... .......... <br /> Number of living'units:!' ---- Number of bedrooms—'------Garbage. Grinder-77= Lot Size <br /> -------­- ------- <br /> ...........Private <br /> Water Supply: Public System and name ---------_---------------- <br /> Clay Loam 0 <br /> Character olf�oil to a depth of 3 feet: Sand El Silt 0 ..Clay F-1 Peat 0 Sandy Loam;R <br /> Fill MoteriolN <br /> Hardpan ❑ Adbbe if yes,type ---------------------------- <br /> etc. must be placed on reverse side.) <br /> (plot plan, showing size of lot, location of system in relation to wells, buildings, <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> 4; --- ------ Liquid Depth .-4-------------- ------ <br /> PACKAGE TREATMENT SEPTIC TANK,!K Size <br /> Capacity C44 aterial---CV-1v ��---- No. Compartments ..... . . ... <br /> JiW Type Ad -------rM J <br /> Distance to nearest: Well -3_pr-? ' -..--..Foundation ... ............. Prop. Une16?__AX.4-------- <br /> ------------ <br /> ------- Total Length ..... <br /> LINE No. of Lines ----- - Length of each line.. <br /> LEACHING <br /> V Box ----- Type Filter Material Ad erial ...jqql...... ............ <br /> .A__R,0P <br /> -k--Depth Filter Mat <br /> Distance t 1 0 nearest: Well ...0_9 ation ....40------ ------- Property Line <br /> ............. Found ------- Rock Filled Yes 0 No 0 <br /> SEEPAGE PIT Depth .............. Diameter ...._--------- Number <br /> ---------.--,,Rock Si;E6-.......................... <br /> Water Table Depth ........... <br /> 10 nearest: Well --------------- ---------Foundation --------- .................. <br /> ...... .... Prop. Line <br /> Distance t .... .....Date �-----­---------------------- <br /> REPAIR/ADDITIO (Prev. Sonitotill Permit# ------ -------------- <br /> . .......... ------- ----------- <br /> .................................. <br /> Septic Tank (Specify Requiren4ts) ----- --- -- --- ---- ........................ ......... > <br /> k I t-n :07=---------- <br /> ements) -C...... <br /> Disposal Field (Specify Requ <br /> 5....... - m ----- <br /> _eA > <br /> - ------------------ <br /> -- -- ---- --- --------------- ------------------------------------------------ *----------------------*------- <br /> - --- ---- --------------------- --- --- --- --- (Draw existing ond­r,e_'q'_,u,ired addition on reverse side) <br /> I hereby certify that 'I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen. <br /> sed agents signature certifies the following: hich this permit is issued, I shalt net employ any person In such manner <br /> "I certify that in the performance of the work for which <br /> as to become subject to Workman's Compensation laws of California," <br /> 1. Signed 7-4 _-it------ -------- ....... Owl-' <br /> Title - - - - - - -- -_.___....".____._..- <br /> (If <br /> --- --- - ----- --- -------(if of er t an o <br /> FOR '-DEPARTMENT <br /> DAT <br /> APPLICATION ACCEPTED BY -------- --- ................. ------ --- --- -- ---- ............. DATE --------- -------­ ­-------------- -- -- <br /> --------L............- <br /> BUILDING PERMIT ISSUED ------- -- ----------------- <br /> "-- ------------------------------------ -- - . . .......... --- ---------------1-1----------------- <br /> ADDITIONALCOMMENTS ------ ----:--�---- ..................................................... -- . ............ .. ...... ........-----------------------­--------- <br /> ----- 1-1- <br /> -- ------ ------------------------------------ <br /> -------- -----------­------- I..... ..... --------- ------------------ ............_­...... <br /> ................................... -------............................................................................. ------------ <br /> Fina-'"i-Inspection'" -,"--, ...by: -- <br /> ----­------------------ -------------------- ----­­....... ------------------------------;....... ---------Data -----------------------__---------- <br /> SAN JOAQUIN LOCAL HEALTH DISInUGT'• <br /> C U 0 1-'AR Rev. 5M <br />