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FOR Ol`Fitli USE. APPLICATION FOR SANITATION PLUM C C. <br />.................. ............... <br />it <br />lComploo In Trlpflcave) ....... . ..... . .... <br />........ . ....... 4-V I <br />.... ...... I �. 4. Datelssued.- <br />.. ....... I This Pornift Expim I Yew Fmn Date I"usd <br />Application is hereby mode to the Son Joaquin Local Health District for a permit to conshi;d and hwhsll the work herein <br />described, This application is made in compliance with my Ordinance too. 549 and existing Rules and RequkMon&- <br />JOB ADDRESS/LOCATION................ C� TRACT ........................... <br />Owner's Name .... J ......... ............... ........... ............. Phone <br />Address — .......... ......... ... . ... .. <br />of <br />ry. <br />Contractor's Name ... <br />. . . .. ........................ ........ JJcW"e!# --- Phone <br />Installation will serve. 1 Residence OA06iinier4 "W50-0, commercial orraffat oxmt 0 <br />MOW0 Other -................... I ...................... j <br />Number of living units:..../... Number of bodroorns L3� .... Gorbc" Gtkw�� .. KI Lot �Ze ------- ------- - - <br />Water Supply. Public Syste 'and name ....................... .- . $ <br />m--------- - -- ...Privatelcr <br />Character of soil to a depth of 3 feet. Sand'] Slit 0 clay 0 Pact 0 SO* Loorn 0 a" Loarn <br />6 - I <br />Hardpan C). Fill M6Wk4;--0- If fres, type............... ......... <br />. .. . ..... ........ ........ ... . ...... .. . .... . ....... .. . . . .... .. .... <br />(Plot plan, showing size of lot, location of system Itl(tolation to wells,' bulldhVs, atc. must be placed on reverse side 'k, <br />NEW INSTAUATIt', N. {No septic tank or seepage pit permitted If public -�w3V►ier Is available within 200 feet.) <br />PACKAGE TREATMENTif ] <br />LEAC14ING LINE <br />SEiPZG'EP:IT- <br />SEPTIC TANK 1;1 . <br />Capacity .................... Typ <br />Size...... <br />Distance to nearest, Well ..... . . ................. <br />.... ..... ....... .............. Liquid Depth ............... <br />... . .. No. Compartments ------- <br />Fours dation ............ ! ......... Prop. Line ................... .. <br />No. of Lines -- .................... Length of each. firm-.... ..... ................. Total Lenwh ........... <br />'D' Box ............ Type Filter Material Filter Material ........................... - ---- - ---- <br />Distance to nearest, Well ------------ " Line ........................ Property ................... <br />--- Dilantjr— -.lDiameterNumber ........................... Rock Filled Yes 0 No <br />. -='77 <br />4 <br />Depth I .......... --.- ... <br />V Water Table Depth . .......... .................. - ....... --.Roa size ....... ...... ........ <br />Distance to nearest: Well ...........,_.............................Foundation ... ........ Prop. Lino .................... r, <br />REPAIR/ADDITION(Pray. Sanitation Permit# ...... Date....••--) <br />Septic Tank tSpecify Requirements) . ..................... 11 .... ................. , <br />-- - ---------------- <br />Disposal Field (Specify ReqLirements) <br />. . ....... . ....... <br />............................... ........... .✓.......... ............................ ..... <br />i <br />............... ........ - .............. __­ ....... ...... .......................... ...... .................... <br />]Draw existing and required addition an reverse *side <br />---- <br />I hereby codify that I how prepared this *Wlcciiiien tine! -that the, wo& wM be do" In accordeaft vA* Sept Jeaqvin <br />C.*unty Ordinances, State Laws, and Rules and 111*961411ons of the tan Jlo"ulln Local H*W*. 010deL Home "Mor W 1l016. <br />sed agents signature certifies the following: <br />"I testify that In the pertarman" of the work for which this pornift Is Ustioct I sha net oniviley any w"M In so <br />as to become subject to Workman's <br />Co-m-ponsado -of-co-wer"le. <br />Signed ....... ...... ...... -------40w <br />1w <br />"I....... <br />By .... .WTitle ---.-.. <br />-- <br />0th n owner) I <br />FOIL, <br />_WE ONLY <br />APPLICATION ACCEPTED BY,,.. ......... .. .......... . .............. DATE ... <br />BUILDINr, PERMIT ISSUED ., ...... *1L .............. ........... ......... <br />.1W -1n . ............... 4, vi;. i'� <br />ADDITIONAL COMMENTS <br />...................... <br />... <br />........... .... ------ ........... ...... ....... -- ............. ............... <br />Date ... ............. <br />................. .............. ...... 1--.1 11 <br />,-00 ....... ........... <br />Final Inspection <br />e4 Rev. 514 SAN JOA N LOCAL HEALTH DtSTRla 8/7h 3M <br />C <br />