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fQR OFFICE USE. <br /> APPLICATION CATION FOR SANITATION PERMIT <br /> f'/ ......­......­..................._ — <br /> . ....... ............. ...................;................ <br /> {Complete In.Triplicate) Permit No. ...- 6 "......... <br /> ................... ............... ........... <br /> This Permit Expires I year from <br /> Date Date Issued -1 C- 7J <br /> Issued ....... <br /> Application Is hereby made to the Son Joaquin Local Health District for a perm.it to construct and Install the work h.erein <br /> described. this application is made in compliance with unty Ordinance No. 549 and existing Rules and Regulations, <br /> JOB ADDRESS/LOCATION -A. <br /> ... ...... .. <br /> .........CENSUS TRACT ........... .............. <br /> Owner's Name .......... <br /> ... .... . ... ... <br /> Address ....... . .........................:................Phone ........................... ......... <br /> Contractor's Name .......... f..... ...........I city�.........­­­..................... .......... ... <br /> .. .... .N.- _0---�Ut7................... ....License # 4hone ... ... <br /> Installation will serve: <br /> Residence 0 Apartment House 0 Commercial CTrollef Court <br /> Motel C3 Other <br /> Number of living units:-._L_ Number of bedrooms <br /> .......Garbage Grinder .............Lot <br /> Water Supply: • <br /> Public System and name ........ ....... size &A.,k...... <br /> -—­ n----------------- ..........*...........*......­Private ❑ <br /> Character of soil to a depth of 3 feet, . Sand Slit[3 <br /> Cloy 13 Peat 0 Sandy Loom <br /> Clay Loom <br /> Hardpan 0 Adobe f3 Fill M6terlol ..............if yea,type................ ...... <br /> Mot plan, showing size of lot, location of system In relation to wells, buildings, etc, must be Placed an reverse side. <br /> NEW INSTALLATION: (No septic tank or seepage Pit Permitted If public sewer is ova within 200 feetJ <br /> able <br /> PACKAGE TREATME EPTIC TAN�K)<. Size.......... .......... Liquid Depth ............................ <br /> Capacity .................... <br /> Type ............. <br /> 7_­ Material-j-�- Compartments ..................... <br /> Distance. to nearest. Well .... Foundation .....__............. Prop. Line ..... <br /> LEACHING LINE. No. of Lines ............. Length of each line.. Total Length ......q. V% <br /> V BOX ....... Type Filter Material ...Depth -Filter Material ...... <br /> Distance to nearest; Well .. I- I................. ........;............. <br /> SSEPAGE-PZ ........................ Foundation ............ • <br /> Property Une '.102.............. <br /> Depth <br /> ---9AIdDlometer .............. Number .........J....... ....... Rock Filled Ye No: <br /> Lia <br /> Water Table Depth ........... .........:.........Rock Size ..../ / SA 0 <br /> Distance to nearest: Well _*.............. <br /> REPAIR/ADDITION}Prev. Sanitation'Permit# ..... ..................k. Foundation .......... .... Prop..Line .;?-o............. <br /> . .. ............ Date ....... <br /> Septic Tank fSpecify Requirementsi. ...� <_ <br /> .......................1-11111"1111--_ _:......4__ <br /> Disposal Field (Specify Req.uirementsl ------------- ........... ........­.­......... ................ .....................__............... <br /> .............................................................. <br /> .........................I........... <br /> ............................... .................. --------- <br /> ................................................................1....................... <br /> ..................... ................I....... <br /> .............................. .....................­........ <br /> (Draw existing and required--- ...............••••---._..:___ <br /> on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqipin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. <br /> sed agents signature certifies the following- Hoint owner or 111cen- <br /> "I certify that in the performance Of the work for which this permit Is Issued, I shall not employ any person in such man' <br /> as to become subject to Workman's Compensation laws of California.— now <br /> Signed <br /> By ........ - <br /> ------ ------- Owner <br /> erlithon ow Per� ......... Title _........ ....... ....................... ................ .......... <br /> FOR�DEPAR�TMENT USE ONLY <br /> APPLICATION ..ACCEPTED WY7.. ....... . . <br /> .......... DATE ..,.Q e7�-1-17 <br /> .................. ......... ...... ....... <br /> BUILDINO PERMIT ISSUED ..........'-. ...... DATE .—, <br /> ADDITIONAL COMMENTS ..................... * ............. ............. ............... ----_--------...-.DATE <br /> ............ . -------­-­---L..............................................................I............__.........­1......................... ...... <br /> ................ -----------------­�................ .........­­­...... ---------_------- ....... <br /> ­ <br /> ------------------- <br /> -------------- ........................... ....................1­­ -- -------------- ......... .............. .............. <br /> F...........I............... ....... ........... ...... ------ ------- ................. ....... <br /> inal Inspection by: .......... ........ ......................... ........ r............... <br /> EH 13 24 1-68 Rev. .... <br /> .. ................... Date .�f <br /> ... . . ........... ........... ............................ <br /> ---- ---- ------- ---- <br /> SAN JOAQUIN 'LOCA HEALTH DISTRICT <br /> 3M <br />