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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .................. <br /> 0. ............... (Compi*to In Triplicate) Permit, No. ..................... <br /> .................. ­�, V, <br /> t�?A! Date Issued ........ <br />........................................................ This Permit Expires I Year From Date Issued <br /> Application is hereby mode to the San Joaquin Local Health District for a per'mit 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 S 1125 to.. .............................................1�aNSUS TRACT ..................... <br /> Owner's Name ........ ......... ...................................................... Phone ................................. <br /> A .4./Q.. I...................................... <br /> Address ...... ...... ....................... City <br /> U4.4r..^..................................................License Phone <br /> Contractor's Name .. <br /> Installation will serve; Residence jj Apartment House 0 Commercial OTraller Court 0 <br /> Motel 0 Other ............................................ <br /> Number of living units ............ Number of bedrooms .....Garbage Grinder Lot Size ............................................. <br /> Water Supply: Public System and name ............................................................................................................Private 0 <br /> Character of soil too depth of 3 feet. Sand IX Silto Cloyo Peato Sandy Loam o Clay Loomo <br /> Hardpan 0 Adobe 0 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 seepage pit permitted if public sewer is available within 200 feet') <br /> PACKAGE TREATMENT SEP IC TANK( I Size.............................. ..........7.". Liquid Depth ......................... <br /> Capacity ..... ............. Type .................... terial................... No. Compartments ..................... <br /> Distance to nelwest: Well .............................. ....Foundation ...... ............... Prop. Line ...................... <br /> t <br /> LEAC9YOLINE No. of Lines ...AZv4:........ Length of each lin .......... 9 *40................ <br /> V Box Type tar Material .......... ter 'Material .................................... <br /> Distance to nearest: Well .. ..... ..... nclati .0.............. pro Lim ......................... <br /> SEEPAGE PIT Depth .. <br /> .. ....... ,doter . ........... Number ....0.... ............ Rock Fill yo&,�je <br /> a le Depth ....... ...........*.-* Rock Size ... .................... . <br /> Distance to nearest: Well ............ ....I......Foundation . . .......... Prop, Line .... .............. <br /> REPAIRADDITION(Prev. Sanitation Permit# ......................................... Data .............. .................. <br /> Septic Tank (Specify Requirements) .............................................. ... ........I ......I........... .......... ....... ........ <br /> .................... <br /> Field (S <br /> at .:� 0� .........10 <br /> cif . . .....;.. ... <br /> Disposal F gei y Requirerri 7� . ........... <br /> 4:2�. . . ..... <br /> �2. ... . .......4u ..... <br /> .............. ....... fe%--:W...... ................ ............................ <br /> ...........I.................................................................................................................... ... <br /> (Draw existing and required addition on reverse'4jW**......... ...... <br /> I hereby certify that I have prepared this application and that the work will be don* In accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District.,Home, owner or Been- <br /> sod agents signature certifies the following: <br /> "I certify that in the performance of the work for.,which this -permit Is Issued, I *MN not employ WW person In such manner <br /> as to become subject to Workman's Compensation-laws of California." <br /> Signed .....2..,f1Z9..A0:20�. .................I.......................I.................. Owner <br /> yl ....... ............... ................... . .................. .......B . . . . ...... . . . ... . .. .... ............ .. .... . <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...... .. . . . . . .. ................................I..... ......... ......... <br /> DATE ...r ...... �V-ZY..... <br /> BUILDINGPERMIT ISSUED...........................I....... ...................................................................._4ATE ........................................... <br /> ADDITIONAL COMMENTS . .. <br /> ............... ............. . <br /> .............................. .......... ...................I...................................... <br /> ...............................................................................................................................................................I.............................I........... <br /> ...................................................................;.................................................................I............................... ............................... <br /> ............................................... ...... ...................................................................................... <br /> ,;�.................... <br /> 4g rZAP.— <br /> Final Inspection byr............... ....... ...........................................................................Dato ........ ........ ..?..,Sl.'.......... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 '24 j.'68 Rev. 5M, 7/72 3 X <br />