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Rio <br /> 9 .T <br /> ` FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.! <br /> • � - (Complete in Triplicate) <br /> Date Issued Q 7 <br /> ................................... <br /> This Permit Expires 1 Year From Date Issued � in <br /> s�„�,-- •, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hero ;. <br /> in described.This application is made in compliance with County Orance No. 549 and a 'sti )tules and Regulations: <br /> - <br /> 3D _CENSUS TRACT <br /> 5�1 <br /> +" JOB ADDRESS/LOCATI �... <br /> f............. <br /> Phone .. a� <br /> ...._.. <br /> 1C.[r:!v......��'�4 ........................•, / r � <br /> }. Owners Nome .... . . 7 sl.t •_ <br /> . ..... <br /> Address ._......Gry <br /> Phone �6 i K� <br /> ---......License# ..... <br /> .T aG .; <br /> • Contractor's Name ----•-•• •••- <br /> Residence House Commercial ❑Trailer Court <br /> Q . <br /> = ' <br /> Installation will serve: t <br /> Motel ❑Other.................................•--•--•--• �t� ���,I 'rig,tg �x <br /> - Number of living units:..../....... Number of bedrooms <br /> ......Garbage Grinder .t��,,i Lot Size <br /> 7� .r9�%4"�• <br /> - ....... Private } f. <br /> Water Supply: Public System and name ....... <br /> .............................- ••• <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ ClayPeat❑ Sandy Loam ❑ Clay Loam❑ dry, <br /> .M <br /> 1 .T Hardpan E] Adobe ill Material ............If yes,type, ..... .. zrtlr e-c �% <br /> t <br /> �~ <br /> e placed on reverse side.) <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc must b <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ,O <br /> a _...: Liquid.Depth ..: W <br /> SEPTIC TANK[ l Size............................• <br /> PACKAGE TREATMENT [ ] No; Com artments <br /> Capacity .................... Type .................... Material....__...._..._ P <br /> Distance to nearest: Well <br /> Foundation ....... Prop.Line <br /> ' Total len th • ... <br /> "i LEACHING LINE [ ] No. of lines ..._....... Length of each line............................. 9 <br /> ' 'D' Box .__......... Type Filter Material ....................Depth Filter Material ; <br /> , . .................. •Pro a line ..................... , <br /> Distance to nearest: Well ...................... Foundation P <br /> SEEPAGE PIT [ ] Depth <br /> Diameter ................ Number ............................ Rock Filled Yes ❑ No O ... <br /> Water Table Depth -----------------•---•--.----•-_.---------••... <br /> .Rock Size .._ ................ <br /> Distance to nearest: Well ........................................Foundation Prop. Line ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......................................... <br /> .. Date ..................................) <br /> Septic Tank (Specify Requirements) ...............•----........._...........�. - �•s'��•��,� .2f......... <br /> Disposal Field (Specify Requirements) ...... <br /> ................. _...... _. <br /> ....................... .. <br /> ... -" .. (Draw existing and required addition on reverse side) „ <br /> ne in <br /> ce with Son <br /> quin <br /> 's that I have prepared this application °onsnd tof the San Joaquin LocShat the work will be oHealth Disirictnmom* owner or licen- <br /> hereby certify P P <br /> County Ordinances, State Laws, and Rules and Regula: <br /> sed agents 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 <br /> as to become subject to Workman's Compensation laws of Califomia-" <br /> Owner <br /> Signed 1 <br /> r� ............................... Title --- r).1. ....... <br /> ` (If other owner) <br /> { FOR DEPARTMENT USE ONLY <br /> _ DATE.�.'� "••-_•_.••••••••-- <br /> APPLICATION ACCEPTED BY . - ��!L. =" G...................' _................_.,.........._._.•......:.........:........ .......:......._...:._._.... <br /> ................................................. .. <br /> DATE ...................... <br /> BUILDING PERMIT ISSUED................... ... .. <br /> ADDITIONAL COMMENTS........................... <br /> ...............................................................................................................................• .'........... <br /> .......................................................... <br /> .................................................... ..............._.................._............. <br /> .................. <br /> ................................•......... .. <br /> /� ���'� .... <br /> •...... ................... <br /> -•----..--......_._ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E.H. 9 1-'68 Rev. SM <br />