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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> le .......... (Complete In Triplicate) Permit No. <br /> I ............. This Permit Expires ? Year From Dato issued Date IssueeP: ?r.=26 <br /> Application is hereby made to the#San Joaquin local Health District for a permit to construct and Install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ................... .....................CENSUS TRACT$c MP.0............ <br /> Owner's Name ..G'4.s,...W4:g.en.k1Q.XXex......................... <br /> Phone9.5.7.3.$ <br /> Address ..S.ame... .... .:......... ._................--...__ .............-.....------............. City <br /> Contractor's Name .G---&..-4.:.5�pt e---Tank...Spar.._.............................License # 3R--5.7?n:2 ,... Phone 30,3933:..:........ <br /> i <br /> Installation will serve: Residence4d Apartment House t] Commercial ❑Trailer Couit <br /> Motel ❑Other..- ' <br /> Number of living units......_-_ Number of bedrooms Garbage Grinder .. Lot Size <br /> k Water Supply. Publ!cySystem and name <br /> . .............................private ❑ <br /> Character of soil to a depth of 3 feet: Sand E3. Silt❑ Clay ❑ Peat[],— Sandy - <br /> ,Loom ❑. Clay loam ❑ _ <br /> i�. Hardpan 0 - Adobe 0 Fill Material ....... Ylf yea type <br /> 1, <br /> (Plot plan, showing size of lot;,location of system in relation to wells, buildings, etc. muss'be'p1aced on reverse side,` <br /> ` f , �""" <br /> NEW INSTALLATION: (No septic <br /> sTAMC tank 'or seepage pit permitted,if public-sewer is available within 200 feet,) <br /> ( ] SEPTIC <br /> PACKAGE TREATMENT ] <br />� Size................................................. Liquid Depth .......................... <br /> Capacity ------------------ Type .................... Material..---- ........... No. �Compartments <br /> Distance.to nearest: Well ------------------------------------Foundation .......................;Prop. tine ...................... <br /> LEACHING lkNl: <br /> 'ifk <br /> [ ] No. of Lines ------------------------ Length of each line............................ Total Length <br /> 'D' Sox .-.-...-.-.. Type Filter Material ................Depth Filter Material .................................. ........J.N <br /> Distance to nearest; Well ........................ Foundation --..... ......--.... Property Line ... ................. <br /> SEEPAGE PIT [ J Depth ._...!----- -•---- Diameter -------------- Number ............................ Rock Filled Yes ❑. No�. . <br /> r <br /> Water Table Depth -Rock Size . <br /> .... .................... <br /> Distance to nearest: Well ...............:................:... ...Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ................... . __-;'...-.-_ Date ........_:. - } <br /> Septic Tank (Specify ,Requirements}. .-.. <br /> Disposal Field (Specify Requirements) .70_t'.1P_aQh..hila...Tr?t th---slmp.._4.r _.TIlCI ... 2_t.-...d.�e._��s 3Jd=--•--r.-..... <br /> ----------- ---- ---------­------------- ----------- ---- --- <br /> .:...................---------------------------_-- .--.-------------------•--•-------------------•--.....•-----....•---•----------.._...:........:-��:....-:--._.=--..-.�.�-.:.^. ' <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the werk..will be dans in accordance with San Jooq <br /> ft <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local'Health.Distrlct. Hama owner or licett- <br /> g <br /> sed agents signature certifies the following: T ':r A I <br /> "I certify that in the performance of the work for:whish this .permit is issued 1 shall not employ an" ` ' <br /> P p y y'Person in such manner <br /> as to become subject to Wo n's'Com s Ia aws of California." <br /> Signed --------------- Owner 1� <br /> ------------------ ---•- <br /> i;� <br /> By ---- --•---Title _._4 .ez•-.--.G' & C' e.pt.ic: .dank.-Fero <br /> (I a than ownerl <br /> FOR DEPART ENT USE ONLY <br /> APPLICATION ACCi:PTED 8Y ---7--- -.- - - DATE /, ,�?- _ <br /> BUILDING PERMIT ISSUED --'-... r::.... DATE ......_. .. <br /> ADDITIONAL COMMENTS .................................... . <br /> -• --------•- "---- ------ - <br /> ........... ----- <br /> ----------------------------- -. , <br /> f=inal Inspection b _ - - <br /> P Y `{ ----Bate .� Z <br />- � �3 21a �-6i� �v. 5� �-� � . <br /> SA .t AQUIN LOCAL HEALTH DISTRICT,_ 8/74 3M <br />