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{# K 'OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ...........................................» Pena»Na. .7_�' fb <br /> ........... <br /> . . .. ... '1'L�s pennit Expires I Year front Data Issued Dcr�tsitred.7.�.-��;�� <br /> Application is herabV made to flair Soul Joaquin Local Health District for a Permit to constn;ct and install the work herein <br /> described. This application is made in wnjAioqP with Conn Ordinance N 549 and existing Rules and Regulations. <br /> JOB ADORESSJL,OCAT :- �- �- ..' <br /> . _ ' .... ............................._ ENSUS TRACT .......................... <br /> Owners Name .....--".........................;........._ .................Phone <br /> Address ._... . 'ss _.._K.�, �.�..i .. .. ........ City . — .. <br /> ............................ ................ <br /> . <br /> Gormactar's ldarrtie_.! �a.5�+ ' 4! ..Y�-w aC�+ •. ? .. <br /> . �,�6 /e <br /> .............license# ....... ..........._. Plrorae .................... <br /> I,tstallation will serve: kesidence IgAparlmW House 0 Commercial ClTrailer Court 0 <br /> Motel[3 Other .. r - .. <br /> Number of living units:........ . Number of bedrooms -Z—.—Garbo tsrirtdar ., Lot Size ....,t3 <br /> Water Supply: Public System and nam ...................------».........,._......................»..:_.. ....»...._.___................._..i'rivats <br /> Character of sail to a depth of 3 feet, Sand b Silt 0 Clay 0 , Poe 0 Sandy Loom O Clay loam a <br /> r <br /> Hardpan 0 Adobes,, Fill Mtaterial............ if yes,type............... ............ <br /> (Plot plan, showing six* of lot, location of system in relation to wells.'buildings, etc. must be placed on reverie skis.) <br /> NEW INSTALLATION: (No septic tank or seepage.pit-permltted if publlt sewer is available within 200 feet,)" <br /> PACKAGE TREATMENT ( I SEPTIC TANK <br /> liquid Depth � ' <br /> ._.....,r'l'_._......_..... <br /> Capacityj................. Type Material.., No. Compartments <br /> I <br /> Distance to nearett, Well _.l-C?o'............... ......Foundation ...I t�.'_......... Prop. Line <br /> LEACHING LINE j No. of Lines ... ....:.............. Length of +earn .`...,........ Total Length ........./..e t?.`... .Ur <br /> 'D• Box Type Fitter-Materials- -cc _Depth .Filter Material ...Ile.......................... <br /> Distance to nearest, Wel! J. _..:_.`..__ Foundation .... ............ Property Line ..... i <br /> SEEPAGE PIT Depth ..... Diarneter e ..._.:. Number ... ._._ t� .. Pock Filled Yes 140 (3 p <br /> .....�.»._._... Water .Table Depth.....4 .r:...........................Rode Size <br /> Distance to nearest, Well ....»J............_.................Foundartim ................... Prop. Lime :.._...._....... <br /> t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...- ..___.._. <br /> Septic Tonk {Specify i'tequirernents) ...: :.`...... _ . ....:...».............. ......,.».. .».. .... <br /> Disposal Field (Specify Requirements) .............»....»�..».. ..., .......,. ...,.....,........M_............... ..._...........-..... <br /> ..... <br /> ....................................._.. .. <br /> ... ......I..----I.................. ......... ......,......................................, ................. <br /> ..............................I.....................................- ...................._...........;...................-.......-................,.,......................._......._. ...... <br /> • (Draw existing and required addition art reverse side) <br /> I hereby certify that t have prei►#md this application and #he# the we& wRl be, bens to accsardwrarar with Sant Je"vin <br /> County Ordinances, State Laws, and Rules and, ltegulatitins of ors San Joograla Lecal Hicaitlt,District.Horns owner or now <br /> sod acgents signature certifies fire foitawinge <br /> "I certify that in the perfomance of the work for which this pasrniit is issuod, I shall not empiey any Per"" in 44th maruser <br /> as to becorAsubject to WAWN"n's Cos" laws of... ia." y <br /> Signed ......!:: Al <br /> ,�.. <br /> By ..................(If.. <br /> than owner) ...........J' ........ <br /> . Title _... . ............................... .......... <br /> FOR DEPARTIIlEN'f.USE ONLY <br /> APPLICATION ACCEPTED BY .... .. DATE ....cls" 2............... <br /> BUILDING PERMIT ISSUED ...... ..................................................... DAT.: <br /> ADDITIONAL COMMENTS......_..»....».............. ......................................................................... ........................................... <br /> ....................................................I...,.,...._._..........�.... ... �:,.....�...,..>........»...........,..... .................................................. <br /> snot Inapection�by. .......... .... ... <br /> ................................,.................... <br /> ........................Oats..-. .74.2.......... ...,...,.. <br /> EH <br /> 13 24 1-6#3 Rev. SAN JOAQUWN LOCAL HEALTH DISTRICT 8/74 3H <br />