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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Vie.- Permit No, ---�--5/ <br /> ��---�`----- ------- {Complete in Triplicate) <br /> ------ ------------------------------ <br /> � Date Issued ---C--�3--_/_-� <br /> _-- This Permit Expires 1 Year From bate issued <br /> Application is hereby made to the San Joaquin Local I#ealth strict for a permit to construct and install the work herein <br /> described. This application is made in compliance with Couri{q Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-.-/ _�1 ---L1- S -- ��. 6n/ �G:-:----CENSUS TRACT ----------------•--------- <br /> -~ �'�= - -- - - --- �-- Phone --- <br /> Owner's <br /> Owner s Name - - --- --�-�---- ,max.-s- -- - --- <br /> Address ----I----1:3-11 ..'J' { ' et9�YT ---------------------------------•--' City - /',� T--�c� --------- <br /> f . <br /> Contractor's Name a'� `P= 1f. -=-------License # 77 Phone = <br /> Installation will serve- Residence ,pApartment House❑ Commercial ❑Trailer Court ❑ �' <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----1------ Number of bedrooms :3--_--.Garbage Grinder --- Lot Size -I f1-y1 -Q----_----_------- <br /> r Water Supply: Public System and name ------------ --------- ---------------- ------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay' ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe'❑ Fill Material ----- ------ If yes, 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: (No septic tank or seeps a pit permitted if public sewer is available within 200 feet,) E V <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f Sizes_X- t-?��C�------- -- ------ -- Liquid Depth - --- ------------- <br /> ���� <br /> capacity r <br /> ee No.. Compartments <br /> _-_-__ TYp�% G- afiera ./.: <br /> .. <br /> - - Line ---- :..-.-:-.-.-.- <br /> istance to nearest. l ----------------------Foundationp --------- Prop. <br /> LEACHING LINE [ No. of Lines <br /> .V ---------- Length of each line----..,V' ---------- Total Length :-- --------------- <br /> 'D' Box 69W-4----- Type Filter Materia Qd <br /> � --Depth Filter Material- -.-1g - ------ <br /> c + i <br /> Distance to nearest: Well _�S 4_- ----_--__- Foundation __4?----------------I Property Line .-,-s.-___---_.._.--- <br /> Depth ---!9/---------- Diameter 0_X/ ----- Number ----------�---------.--'!Rock Filled Yds 8—No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------„-.---- -----;s--•-------- t <br /> i <br /> If Distance to nearest: Well --------i� -(--------------------Foundation -- fv` Prop. Line; -----A------------- <br /> I 1 , <br /> ------ Date ------------ --'"-------!-------•- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- --------- ---------- ----- - ) <br /> Septic Tank (Specify Requirements) -----_-------------- ,7/ ° ` --------------- _1-"-- <br /> i Disposal Field (Specify Requirements) ------------ -------------------------- -------------------------.------------------------ <br /> :. ; <br /> € - <br /> -------------------------------------------------- <br /> 1. <br /> . r ii .- F <br /> ----------------------- <br /> - <br /> -- ---- -------- -----(Draw existing and required addition on reverse <br /> side) <br /> r' w' <br /> + I hereby certify that I h6",prepared this appliccition-ari l-Act' the work will be done in:aci:ordance with San Joaquin <br /> County Ordinances, State Laws,,ancl Rules and Regulations of the. San Joaquin Local H€altW'Di�strict. Home owner or licen- <br /> sed agents signature certifies the following: ' <br /> k "I certify that in the perfor nce of the work for which this permit is issued, I shall not employ:any person i such manner <br /> as to bec a subject to W krnan' o pensation laws of-California:"- - - <br /> Signed ------------ - --------`--- -----,----- Owner �s <br /> Title -------------------------------- L". <br /> -------- -------- <br /> -------------------------- <br /> (If other than owner), <br /> ;• FOR DEPARTMENT' USE ONLY l <br /> APPLICA710N ACCEPTED BY? = _ -- --------. DATE ------ �f /_,3=�- <br /> BUILDING PERM17'ISSI�ED._.--____w__--=- }---- - = =='R� =m__'___' = ==" -- -------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------ -------- ------------------------------------•-------------------------------- ------------------ <br /> -------------------- -------------------------------------------------------------------------------- <br /> . - ---`------------------------------------------------------ -------------- -----k <br /> - til <br /> Final Inspection b -------Date --- --�' - --� - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />