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FOR OFFICE USE: <br /> M :- R _� �,,� APPLICATION W1t SANITATION PERMIT <br /> x. YI oC mpiete in` M) Perm It No.:.. .............•--, <br /> .....f. ,..... ...... mss.- - - <br /> S <br /> This P.4mit Expires I Year From Date Issued f slued . <br /> `Application is here_�f made to the San Joaquin Lo al Health District for a permit to construand <br /> descri(aed. This application Is made In compliance with County Ordinance No. 549 and existing Rules#and Regulations,the work rein <br /> JOB ADDRESS/LOCATION.......... ' _. _...... .....�rC -t.:. ........... :.. <br /> CENSUS TRACT I ........................Owner's Name .. .� (�' Z.... .:_.. .. <br /> k r Ph <br /> ................... . ....... <br /> Address <br /> i . = c_. .................• ---• <br /> --. Ci <br /> :Contractor's Name _I -Gt ,. <br /> t` .�- �1---,�Lf.license # Phone �Q <br /> #nstaflation wi#t serve: ResidenceXApartment HousetO'Commercial[]Traiitei Court <br /> ` Motel[]Other__. --;----- ..... <br /> de <br /> i Number of living units:_._..__ Number of bedroom <br /> Water I <br /> s Garbag Gander .---- '' Lot Size <br /> Supply. Public System and name <br /> --••--';..� "' .__.. - •---•-- � __Private❑ <br /> Charade of soft to a depth of 3 feet: Sand• Sift❑ Clay [{ Peat❑ Sandy Loam ❑ Clay loam 0 <br /> Hardpan D Adobe W Fill Mas erloi ...••_-- If es <br /> -. . t <br /> yes,type ............... ............ <br /> 4 <br /> {Plot plan, showing size of lot, location of system in relation to wells, I;vildings, etc. must be placed on reverse side.) <br /> NEW INStALLATlON: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,') ; <br /> 'PACKAGE TREATMENT ! / <br /> € [ ] SEPTIC TANK Yip Material Liquid Depth ....Size.-------•�. e- <br /> i Copacity/r � ��1 aT <br /> :. al No. Compartments s ............... <br /> l51 <br /> Distance[to nearest: Well �' - _ / <br /> ` Foundatio P. <br /> LEACHINd­LINE_�No--ofAines ,r Prop. tin <br /> �f '.."'..-..' 'Length o ecrcf►(irie.: = ---.. _ gtifi" <br /> To#a-"1"''Len f� f <br /> D' Box ... . _..... Type Filter Material -- Depth Filter Materia( .._. � <br /> Distance to nearest: Well � .Foundation ._..#� .---•. <br /> ....... Prope L!r►e a � <br /> SEEPAGE PITp rtY =-i •---•_......_.._ (�[ <br /> . _.. Depth p� '. --_-- biameter -d/_ Number .........../----------- -- Rock Filled . Yes No'O ' <br /> l <br /> Water Table Depth _.._... R <br /> t Pt �....-fi..l•------...--••---=Rock Size .... <br /> Distance to nearest: Well <br /> "L----•---Foundation <br /> ' - --..�lrr�...-.-----. Prop. Line _._.:�.�-.-----� <br /> " REPAIR/AboiTIONWrev..Sanitation Permit# ............_...__. ......... <br /> . . . ....... pate ............................ <br /> E Septic Tank (Specify Requirements) ) t--y---1 <br /> ---------- -•-- <br /> + i Disposal Field (Specify Requirements) .......:..... <br /> -------- ---------- <br /> ••---•--------•------- <br /> -• --------------- -------- .........--••----•--•--- ------ ------!,...:..... <br /> ____________________________"__._.__--_.__..__ _ __..._ <br /> _ __. <br /> I (Draw existing and required addition on reverse side) ------ 5 = <br /> !'hereby certify that I have,prepared this application and that the work will be done in accordance with}5an Jaaquftt <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Houle owner or licen• <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 em la an <br /> as .ro become subject to Workman's Compensation laws of California." p y y person-in such manner <br /> � e <br /> Signed *... ..... ........... ... .Y_.. <br /> k ..............• <br /> �.._ Owner 7171 <br /> ....1 _otherthan <br /> FOR DEPARTM. V NL <br /> APPLICATION ACCEPTED BY ......---- -•---..."-- - �. ; <br /> -: <br /> BUIL©ING PERMIT ISSUED ------------ ---------�"u--- ...... -- •---_._.._.... DATE .. .`�'��-------------------- • <br /> ADDITiONAE.. w - ,.�..-. .... ....--• .._ . <br /> .._.._ _ ...-- --•-• DATE. <br /> -------- ......••----•-•--- -- <br /> -_= <br /> ' "a <br /> - _ ............. ................. <br /> - - • ....._. ------ . <br /> Final Inspection 6y: .--- ....---------------------•--.._....._...- " <br /> ... .._.' - .. ....................Date .. . .--. 0_^ . <br /> EH 13 2h 1-68 <br /> f ANrJ At�UIN LOCAL HEALTH DISTRICT 8/711 3 <br />