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r`;Ips <br /> FOP (-F;;CE USE <br /> APPL{CATION FOR SANITATION PERMIT <br /> Permit No. <br /> IComplote In Triplicate) <br /> � Date Issued <br /> -� This Permit Ex:-fres 1 Year From Date icsu*d <br /> Application is hereby made to 'Ire San Jnnquin local He4'th D,orict for a permit to construct and install cher work herein• <br /> described This application ,s mr7de Il, rompl;once with County Ordinance No. 549 and existing Rules and Regulations, <br /> 10B .ADDRESS40CATIC)N ?,r� ! `r J ` ` CENSUS TRACT <br /> Phone +i <br /> Owner's Name <br /> Address ".J , • '� 4 ' <br /> City <br /> 1? . /• .. . license # �r ? Phone li <br /> t:antractor s Narne 4 '� - J� ` <br /> Installation will serve: Rrt tierce ❑ Apartment House i� Con,mmrcial (]Traller Court C3 „ <br /> motel I']Other Jt <br /> tdun)her of bedrooms Gnrbago Grinder lot Size <br /> �Jumbe! of living units: �.�.� <br /> Private <br /> Water Supply- Public System and name <br /> Character of soil to a depth of 3 fort Sand [] Silt❑ Clay [] Peat[j Sandy loom ❑ Cloy loam [1 f <br /> Hardpan �J Adobe F1 fill M01—al ^If yes, type <br /> [Plot plan, showlna s�:e of lot, lorrtion of system in relation to wells, buildings, etc. must be placed on reverse side.) c,.f ¢ <br /> NEW INSYALLAYION: 'No septic: trtnk or seepage pit permitted if public sewer is ovaila)ao within 200 feet.) Esq <br /> Depth Liquid - •• c/� <br /> PACKAGE TREATMENT 11 SFPTIC TANK I j Size li 4 p 1 ti' <br /> Cr,parity Typo <br /> Material No. Comportments 4 <br /> Distance ry FovndaYon Prop. lino nearest- Well ,_ <br /> I FACHING LINE ( NO of i Iney <br /> s length of each line Total length <br /> Type Filter Material Depth Filter Material <br /> Dlstrn- to nearest: Well Fovndotion Property line <br /> ;FFPAGE PIT i IDepth <br /> Diameter Numb*- Rock Filled Yes ❑ No <br /> Water TohI„ Depth Rock Site <br /> Foundation Prop. line ....... •.•. <br /> D-stanrn 10 --rest: Well •• `� <br /> REPAIR/ADDITION(Prey Samtar,on Permit# Date f <br /> Septic Tank (Specify Requ,ten,ents) <br /> Drsposnl Fteld iSpec,fy Requ;rerv,ents) j I <br /> il�aw existiAg and required addition on reJarse side) <br /> hereby certify that I hove prapr•red this application and that the work will be done In accordance with San Joaquin , <br /> County Ordinances, State laws, and Ruses and Ratvulations of the Son Joaquin Local Health District. Homo Owntsr or licon• i <br /> tvd agents signature certifies the following: stern ii. su<�. ,"'unnvr <br /> "i certify that In the performance of the work for which thin Perwslt Is iswrd, 1 shall not employ any H <br /> as to become subject to Workman's Compensation laws of %:allfornio.” <br /> Owner <br /> tlr ; r I v �61i J� Tttlr <br /> (if other rt..I„ r;.:•,.•I <br /> FOR DEPARTMENT US! ONLY <br /> i DATE <br /> APPUCAT,UtJ ACCEI ILD N. c< 04 DATE <br /> BUUDa1(; rF.R+,nlT IiStIN" <br /> r.DDITI0PA1 CUMr.�ttif'_, <br /> Date <br /> . .,.,i ,•.r,.....,n l,Y ,. . . . ". ''' <br />