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FOR OFFICE Ut- <br /> APPLICATION FOR SANITATION PERMIT OFFICE USE: <br /> (Complete in Triplicate) Permit No. . <br /> This Permit Expires 1 Year From Date Issued Dare Issued <br /> Application is hereby mode 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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOC ON ���5 1r �i; CENSUS TRACT <br /> Owner's Nam, /% .><-(,���„c r� �.,- -cc �•-:� Phone <br /> Address 9^f <br /> Contractor's Nome City,.-:� <br /> License # ��� Phone _.. <br /> Installation will serve: Residence Fdl Apartment House [] Commercial rl Trailer CorIrt ❑ <br /> Motel r1 Other <br /> Number of living units: Number of bedrooms 'y Garbage Grinder lot Size .3. <br /> Water Supply, Public System and name Private ❑ <br /> Character of soil to a depth of 3 feet: Sind p Silt❑ Clay[] Peat 0 Sandy Loom [f Cloy Loom <br /> Hardpan ji/ Adobe❑ Fill Material If yes,type <br /> (Plot plan, showing size of 'at, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (Nu septic tank or seep ge it public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK I <br /> Size t <br /> Liquid Depth <br /> Copocity e Type Material /<7s z-.% No. Compartments �- <br /> Distance to nearest; Well f `T p. Line <br /> P �/" <br /> Foundation le e Prop. <br /> � <br /> 17 <br /> LEACHING LINE (� No. of Lines 2 Length of each line 7` / Total Length 74" <br /> 'D' Box / Type Filter Material s Depth Filter Material <br /> Distance to nearest; Well <br /> Foundation 1 <br /> SEEPAGE PITd ���.t Property Line <br /> (�' Depth •S PMiameter 7 j �° Number �- <br /> Rock Filled Yes�No❑ <br /> Water Table Depth ` b O Rock Size <br /> Distance to nearest: `.jell Foundation \C .(_ Prop. Line <br /> REPAIR'ADDITION (Prev Sonrtation Permit# Date 1 <br /> Septic Tank (Spec;fy Requirements) <br /> Disposal Field (Specify Requirements) <br /> (Draw existing and required addit on on r'.J•-J e "'dr-I <br /> I hereby certify that I have prepared this application and that the work will be done ir, accordance with Son Joaquin Count, <br /> Ordinances, State Laws, and Pules and Regulations of the Son Joaquin Local Health District" Home owner or licensed age�,t! <br /> signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner rat <br /> to become subject to Workman's Compensation laws of California." <br /> S fined / . Ov.'nf _�1"1 <br /> j " <br /> By )- i tC G-L — ,.-- Tale � !_ <br /> Ilf other than owner) ) y <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �! .j_. _ UATE - <br /> DIVISION OF LAND rJUMBEP <br /> DATE <br /> ADDI T IOi4AL CG1.VAEt:TS <br /> _ f r <br /> F r�, :r,pect on r.Y t �f Date <br /> SAti JGA?Uifi LOCAL HEA1,Tr, r- V,;:..,, a, , ,., <br />