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FOR OFFICE USE: <br /> -- --- ------ ------- <br /> Vie: APPi.iCATiO Complete SANITATION PERMIT <br /> -� - , p Permit No. ---- -- <br /> r <br /> ----------- -- -- - Triplicate) <br /> _______________ , 'r This Permit Expired) Year From bate Issued Date issued __.----____-___-._._. <br /> Application is hereby made to the SanCJoaquin Localf Health District fore permit to construct and install the work herein <br /> described. This application is made in compliance with County,Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRES5/.L�OOjr- - --�p-_ -" ------ <br /> D"-- -------------_CE.NfiSrU <br /> S <br /> T <br /> RACT ----- ------- <br /> Owner's Name % ------1T'r` ' - F--- hone <br /> Address -------- ---------pp -D' ------------------ --- <br /> City -- t'C I <br /> �, ----------• ---------------------------------•------ <br /> Contractor's Name Qt... � . - ---%QU tease # ------------------- Phone ------------------------•- <br /> Installationill serve: Residence 2r<Partment HoCisek❑r Com erdfi6 j❑Trailer Court ;❑ <br /> Motel ❑ Other <br /> Number of living units_____________ Number of_bedro-oms 3-___Garbo e Grinde F <br /> I 9 _ Lot Size � �, .• -�--- <br /> ppY Y. - = ---------=�----- Private <br /> ❑ <br /> Water Su I' : Publi[c 5 stem and name -----__ <br /> Character of oil to depth•h of 3 feet- Sand❑ Silt. Clay ❑ Peat❑ Sandy LoamClay Loam.❑ <br /> Hard <br /> I an Adobe <br /> T11'Material - -- --b If""�yes <br /> — "4 <br /> j P ❑ [❑ -- "","`type -------------------- ------- <br /> (Plot plan, sFiowing size of lot, location of system in relation t+ wells, buildings, etc. must be placed`,on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted-i.f.public sewer is available within 200 feet;) /{ \ <br /> • as � d <br /> PACKAGE TREATMENT [ SEPTIC TANK' Size _-_ _L:fl-_X---_ __""""" Liquid Depth' ._, 4 _. <br /> Capacity Type t o rtm <br /> q p <br /> 1ZE1� Yp �� ' laterial-�4-rt_ r t !1 <br /> -Distance-to-nearest Well Foundation f . ..Prop.-Line ._ '" <br /> 3 LEACHING LINE [.j No. of Lines _._ Length of each line.-- 10 _-`--_ -- Total Length -__�s��f C '..__._ <br /> i <br /> D' Box yam__ Type Filter Mater ial 8064_,__Depth Filterf Material ---_/5-1-1----r--.""_- <br /> ^ r <br /> Distance to nearest: Well �__-7t777--- Foundation ----- Property Property Line, ___ <br /> SEEPAGE PIT [ Depth <br /> I --__ ______________-_ Diameter --_______-_---- Number ------------------------ --- Rock Filled Yes E3No i❑ �. <br /> Water Table Depth ---------------------------- ---------- --------Rock Size <br /> b - <br /> Distance to nearest: Well ---------------------------------------"Found --- <br /> ation ----------------- Prop. Line ...................... <br /> !�1 � . <br /> REPAIR/ADDITION(PrellSanitation Permit#--------• ------------------------------"""-- Date -----------------------------"_"_-} <br /> F Septic Tank Specify IRequirements)s ---------- ---------------------------------------------- <br /> x �F <br /> Disposal Fie]2W (Sped y Requirements} --- '- - }. �- -- -- --- - -----------�7-10.+-.__, <br /> --------------------- ----------------------- --- --------------------------------------------- ----------- <br /> T <br /> - ------------------------- ------ ---- --- ---------------------------------- - :7..... - ... ,.- <br /> ` <br /> (Drawexistingand required additiori_on.reve�e�side}i <br /> . r <br /> I hereby certifyt It I have prepared this' application and that the w®r will be done in accordance with San Joaquin <br /> County Ordinaac-es; State Laws, and Rules and Regulations of the San Joaquin Lo cal Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify tha# in the performance of the work for which this permit is issued, I sh F not employ any person in such manner- <br /> as to become'subjel t to Workman's Compensation laws of California." <br /> Signed ----- ;. ----- I- ------- Owner. Y„. <br /> BY ------------------------------- ------------------------------------------ Title '= <br /> (If other than owner) <br /> --------------- <br /> i <br /> # FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE ----- --`” -, --.-----• <br /> ------------------ <br /> BUILDING PERMIT ISSUED -------DATE --------------------- --------------------- <br /> ADDITIONAL-C-OMMEN7S ------_. __ _ --,, ------- <br /> -------------------------------- <br /> = -c. _ L__ ! t ----------- <br /> --- - � �-�------ U " � � 14 a�C t <br /> ---- ---- - - ---- ---- --- ------ --------- <br /> --- -- ----- ------ . <br /> -- -- <br /> --- <br /> Final inspection <br /> --- - - - <br /> ------ -- Date <br /> c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT =.h <br /> F. H. 9 1-'68 Rev. 5M <br />