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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT <br /> ------------ --------------------------- <br /> 11. 0 6 A- I i_ (Complete in Triplicate) Permit No. <br /> ----------------------------------------------- 11 �S_=�"l�_-�� <br /> — <br /> Date Issued <br /> --- ---------------- --------------:------ ^4 This Permit Expires I Year From Date Issued <br /> Applic/a`t'lon is hereby made'to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> describ6d. This application is made in compliance with County Ordinance No. 549 and existing Rules and: Regulations. <br /> t V <br /> 1 0 1 - 1: 1 <br /> JOB ADDRESS/LOCA -I .. ...jj��-ae4eA_A/_CENSUS ------:------- <br /> kT ON <br /> K,3 Owner's Name ---- --- ------- ---------------------------------- --Phone <br /> City ---------------------------------- <br /> Address _77----------- _W <br /> --------------- Cit w_, <br /> - ------------ <br /> Contractor's Name 01 _t <br /> -- - --- -- ---- ----------License # <br /> -------------- Phone :i <br /> Installation will serve. Residence El Apartment House 1E] Commercial oiler Court ;E] <br /> Motel F-l Other ----------------------------------------- <br /> A <br /> Number of living units:------ Number of bedrooms __-_______-Garbage Grinder ------------ Lot'Size --- <br /> Water Suppiy.'Public System and name ---------------------- ----------•----------;-----w--------•---------------;}-----------I-----------------Private>r <br /> Character de of 3 feet: ' Sand' Sift C] Clay E],,o Peat F] Sciln-dy Loam Clay Loarn 0 <br /> i; Hardpan ❑ Adobe Fill MaterialIf yes, type --------------------- <br /> 0 -------- <br /> (Plot plan, showing size of lot, location of systemAin relation-to wells, buildings, etc. must be placed A reverse side-}., <br /> NEW INSTALLATION: (No!septic tank or seep-a-ge pit permitted if public se'we'r is available within 200 feet,) <br /> OP y, <br /> PACKAGE TREATMENT SEPTIC TAN�P< 'L '_ - �'/.�� <br /> Size Liquid De ----- --- <br /> Pth ----------- <br /> T1 ate No. Compartments <br /> qn o ��,e -a <br /> Capacity6 - -_ --- - ___4 rial_e::2671 ---- 3........ <br /> Distance to nearest,,Well –4t-) I <br /> L -- - - --------------Foundation __/4----------- Prop. Line 2�-- ----2)1 <br /> LEACHING LINE, No.11 of Lines ----0--------------- Length of each line./d0_–,/deJ.n_9'i0TotaI Length <br /> 'D' ;Box .___/___ Type Filter Material Z_PdC/r-'Depth Filter Material ------- -------- ................ <br /> 00 <br /> Distance to nearest: Well ------- Foundation ... ------------ Property Line.,15------------------- <br /> SEEPAGE PIT Depth ------- Diameter :-------- Number ---------g---------0----- Rock Filled Yes No <br /> Wai:er Table Depth -------- -------------- --------------Rack Size --------- <br /> Dist <br /> a" rice to nearest: Well -------- ,0---------------_--Foundation --- Prop. Line ..------------_. <br /> REPAIR/ADDITION <br /> a ---------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_) <br /> ii <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- ---------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------11------------------------- <br /> ----------------------------------------------I------------------------------------------------------------------------- --------------------------------------------------------I------------------------- <br /> ------------------- ------------------- ------------------------------------------------------w--------------------------------------------- ------ ----------------------------------------- <br /> 11 <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have'prepared this application and that the work will be done in accordance w4h Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homeiowner or lice <br /> sed agents signature certiflei�the followingII <br /> - <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 subject to Workman's Compensation laws of California." <br /> Sig <br /> ;l�!---- <br /> ----------------r-------- <br /> -----x__ Owner <br /> B. ycTitle <br /> I pea� <br /> (If other-44n ----------- <br /> FOR DEPARTMENT USE ONLY <br /> BY --------------------------k-------------------------------------------------------------------- DATE <br /> APPLICATION ACCEPTED B ------- <br /> BUILDING PERMIT ISSUED :' <br /> ----------- -------------------------------------------------------------------- --------------DA�TE -------------- ------------ <br /> ADDITIONAL COMMENTS <br /> ---rt <br /> ---------------------------------------- <br /> 7VAUX*&_\�---- -- ----- -----------------i---------------------------------------- ---------------- ------------------------ <br /> --------------------- ----------------- <br /> -------- ---- ----------------------------------------------------------------------------------------- <br /> ---- --------k <br /> -------------------------------------------W-t- <br /> VAL- ------------------------------------------------------------------ <br /> Il <br /> FinalInspection by: -------------------- --------------I. _­-----------------------------------------------------------------------------Date ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />