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FOR OFFIC-E`USE:• � y � <br /> APPLICATION FOR SANITATION PERMIT <br /> - Permit No. <br /> /L� h (Complete in Triplicate) <br /> --- lrf------------------ <br /> Date Issued <br /> ------------------------- ------------------------------ This Permit Expires 1 Year From Date Issued <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 .---Z7Q 3._5------A_�I_STI-1v-.---RTS---.--------f 3APQPV ---CENSUS TRACT ------tom............... <br /> Owner's Name !'C-�- �E-f -��? CHl_11� -------------------------------------------------Phone _. 2�1' t ------ <br /> - h1ANTFK0q------------------------------------------- <br /> Address ',-----al-1-4-T-5-�_R��_I-SGA------------h-p------•-------.License # ---- Phone g��1'6 -�---- <br /> Contracto s Na <br /> Or <br /> Installation will serve: Residence�partment House,[]'Commercial ❑trcder Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-----L------ Number of bedrooms -_2----Garbage Grinder ._V0----- Lot Size _______________ <br /> 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 _-tvQ'-_ If yres,type ____________________________ <br /> (Plot plan, showing size of lot, location of-system in relation to wells, buildings, a rmj is be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is av ilable within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTICJTANK:['} Size------------------------------------F.......... Liquid Depth _________...___.--__- v <br /> Capacity s ------------ - Type ------------------- Material- -- --------------- No. Compartments _-------------------- � <br /> Distance t_a nearest! Well -_________________________________Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ---------__--___--_-_.-.____ <br /> ',D' Box ------------ Type Filter Material _____--______•-___,Depth Filter!Material -------------------------------------------- <br /> Distance,to nearest: Well _______________________ Foundation ------------------------ Property Line _-________-.._____-.---- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------- -+'" �Rprl $ize ^v----------------------- <br /> DistanceJto nearest: Well ------------------------- j--,..Fgyndation ----------- -------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -_-___-_-__._________-------_----) <br /> Septic Tank (Specify Requirements) ------- ---------- ----------- -- _. ------- --- <br /> Disposal Field (Specify Requirements) -------- ------------RED-►HYD D------TA-nl-K--.-- x'11---- =------------ <br /> pa ------CO C- z_ _FA0------ P_TIL_ `t et t --- - ALL-. <br /> -----M11A H-----W_AT)=, --------------------------------------- <br /> (Draw existing and required additit5n"6n revers - <br /> I hereby certify that I have prepared this application and that the work will "e in accordance with-lan Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquiwl.o oil Iealth District. Nome owner or licen- <br /> sed agents signature certifi4 the following: <br /> "I certify that in the perfort6ance of the work for which this permit is issued, I sha not employ any p1§rson in such-manner <br /> as to beco ubjgpt toW n's Cmpe.nlaws of Caldor iQaw."nerSigned -- ........ <br /> ------ <br /> By <br /> - <br /> ---- ------ -------------------------------------------------------------- ------ ------------------------------- ---------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> ------------- - DATE . qG <br /> APPLICATION ACCEPTED BY -----�t-R-0- ------------------------------------------ --------------------------- <br /> BUILDING <br /> ------------ 1 <br /> BUILDINGPERMIT ISSUED --------------------__--------------------------------------------- ----------------------------------DATE --------------------------------- --------- <br /> ADDITIONAL COMMENTS - ------- -- --q ---- - - --------------------- ­---------------- <br /> ----------- <br /> ---- ---------- <br /> __-_------------------------ _____ _________ ________ __ I-.. r ti. - <br /> ----- -' -- ----. -- -------------------- \-- --- ----------'; -- -- -- -- -` •--------------------------- ---•- ----------------------- <br /> :LIZ <br /> ----- - - -------- <br /> ------------------------ <br /> - - G(?j <br /> Final Ins -- '------------------------------•---------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />