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FPX <br /> ot=rlu vsi:: APPLICATION FOR SANITATION PERMIT <br /> ... y `. . _(Comlilete In Triplicate) Permit <br /> ......... .11.Y .- This Permit Expires 1 Year E►oni Oats Ossued �. . "Date lssued P..",�:.... . <br /> k Application is hereby made to the San ,loaqulr'Local Health District for a permit to. construct and Install the work herein <br /> '-.'-described. This application Is madeIn compliance with County Ordinance No. 549 and existing.Rules and Regulations: <br /> J 8 ADDRESSAOCATION . . ........ ........G ---••.............,..................CENSUS TRACT .......................... <br /> Owner's Name ... .... ...... ..'-.. .................. ......:.. ........ .......Phone ..................................... <br /> Address ... --�. ....... ... <br /> ............................. .......City ........... .............. : <br /> ----••...._.. . .. : 2 ..: <br /> Contr`acloi s'N6me .. .�. _ -------•.......................................License Q . .. Phone :� vy J Q�j <br /> Installation will serve: once House Camm. artial- <br /> � <br /> ❑Trailer Court E] <br /> Motel❑Other.................. --------------- <br /> Number of.giving units:-:------:---_.Number-of.-bedrooms'"�. Garbage Grinder ----------' Lot Size •........................--•- <br /> a •_ <br />' Water Supply: Public System and-name s'' ....... .....................................--•..Private❑ <br /> Character of soil to a depth of-3"fe:. wand-0—SIIVEj---\Clay ❑ Peat❑ Sandy ioam;E) Clay Loam ❑ <br /> rHardpan(j Adobe Q Fill Material ............If yet,type ......... ...... . ... <br /> (Plot plan,.showing size of;lot, location of system in relation,to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: Apublic sewer <br /> No septic tank,or seepage pit permitted if. .is-ovailoble within 240 fest,) <br /> PACKAGE TREATMENT'. 'I ] SEPTIC TANK Site................................ ................ Liquid Depth ......................... <br /> Capacity���-- a-- Pe .. �aterial 4.................... No. Compartments ..................... <br /> . Distance to nearest. Well Foundation -JQ-___•--_...... Prop. Line ...................... <br /> r b <br /> t LEACHING LINE I ] �No. of Lines _---------------- Length of each line.......-......... <br /> -___....... Total Length ............................ <br /> _. ;BoxType Filter Matetlal ...Depth Filter Material __•_----_----••............................ <br /> do Distance to neorest: Well Foundation .................. Property Line1 <br /> SEEPAGE PIT I Depth Diameter Number Rock Filled Yes ❑ No 0 <br /> i., <br /> Water Table Depth .....Rock Size .................:............... <br /> ; <br /> Distance to nearest: Well ..................Foundation ....... Prop. Line -------------------- <br /> REPAIR/ADDITION(Prov. Sanitation-Permit# _________________________........................... Date ......_...................1 <br /> Septic Tank (Specify Requirements) ................... -- ....................................... .... ........ ..............._................. <br /> Disposal Field (Specify Requirements) .__... � '.. ... ._ ._. ` ..............................:. ...... <br /> ................................................................_......... ---------........................ ...-•-------=----•-•--. ._.........:................................................. J <br /> R ......... -----•-•••--•............... .. .._. .._..._..._._....-------------------------------- <br /> t. .. .; <br /> ........----- = -----• .............. <br /> (Draw existingand required addition oneverse . <br /> tidal <br /> I hereby certify that I have-prepared this application and that the work will be'done In accordance with San Joaquin <br />_ County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health! Dtsldet. Homs owner or#icer <br /> sed agents signature certifies the following: . <br /> "I 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 subjact to Workman's ComLwnsatlon laws of California. <br /> Si9 w <br /> nod ...... .-----� ----�--•-.. . ... ........_ .... Owner <br /> .................................... Title ......................... ...................................... <br /> F <br /> (if other than owner) f _ <br /> fOlt DEP RT LISlr ON <br /> IY <br /> APPLICATION ACCEPTED...BY .............................. <br /> _ ....... <br /> BUILDING PERMIT ISSUED .....__....- :.::........:.: :.::.. .:.::- ..... , ....,_ ..DATE _:.......... •.`_:--•� i <br /> .� •�•1`r <br /> ADDITIONAL COMMENTS .........:....:................................:..•--•--- •........ i <br /> ............................................................................. <br /> ............................................•----•-•-- ----...._._...-••---.....- ... x..................,.,..............................--.................I.................. <br /> .- :.... .---•-••. --- --...... .... ..... .[... . ._.__... .. ...........-----........._.................. ........ <br /> Final Inspection by: ........................................Date .��.:. ._... j.......... <br /> Edi 13 24 1-68 ftv. !�4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �? % 3r! <br /> J <br /> �i <br />