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FOR OFFICE USE: <br /> /�* APPLICATION FOR SANITATION PERMIT <br /> . ............ <br /> �f <br /> V (Complete in Triplicate) Permit No: 4 <br /> ---------­------ --------- jhis Permit Expires 1 Year From Date Issued /n Issued ILI <br /> ---------------------I------ --------------------- <br /> Application is hereby made to the Son Joaquin Local Health District for d' 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 /> -V <br /> JOB ADDRESS/LOCATION f-)go------- --CENSUS TRACT ----------------I...... <br /> ----- ----Phone 7ev <br /> 0611 ---------------------- ---- -- -- ----—----- <br /> Owners Name ---- ------------ ---- ----- -------------------- <br /> -------------------- ---------------------- <br /> Address,' ------ - --- ---------------------------------- City <br /> Contractor's Name <br /> �114 �-1 ------------------------k��_------- `-----.License # Phone <br /> Installation will serve- ReiidenceX Apartment House-[] Commercial :[-]Trailer Court C]-` %- I <br /> Motel 0 Other --- --------------- <br /> k- :?------- --------------- <br /> Number of living units:-----/--- Number of bedrooms-'t---�/!_Garbcidie�Grinder Lot Size <br /> Water Supply. Public System and name ------------------)---- i-------I--------------'---------------- ----------------------------------------------Private <br /> Character of soil to a depth of 3 feet: So nd'EI\Si It 0 Clay ❑ Peat 0 Sandy' Loam -0 Clay Loam <br /> f <br /> -,,UpEdppp E] Adobe,E]. 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)?ublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK S.ze-/ ----- ----------------- Liquid Depth -------------- <br /> -- <br /> X. :V ----- --- <br /> Capacity/6_0_��__ Typej4e�-_L'1141 Material <br /> --- No. Compartments <br /> Distance to nearest: Well ..........................Foundation 4_6------------Prop. Line <br /> LEACHING LINE No. of Lines --------_5—---------- Length of each Length ............ <br /> 'D Box Type Filter,Material ---Depth Filter- Material --------/_<------ ---------------­---- <br /> Distance'to nearest. Well ----,60-'---7"-------'Foundation ----/_ ------------ Property Line .-:�------- -------`fes---- <br /> SEEPAGE PIT Depth ------ Diameter Number -----------2-------------- Rock Filled Yeso No C] <br /> tw X: Xj'/ e <br /> Water Table Depth --- ----------------------------------Rock Size ----------------- <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) -------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------ --------------------------I--------- -------------------------------------------------------------------------------------------------------------­--- <br /> - ------------------------------=------------------ ------- ---------------------- ---------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I <br /> I hereby certify that I have prepared this applicatipn and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws.; and Rules and Regulations of the San Joaquin Local,Health-District. Home-owner or liven- <br /> sed agents signature certifies the following: <br /> "I certify that in the perform ce of the work for which this permit is issued, I shall not employ any person in such manner <br /> to be e subject t 0 an's Comp laws of California." <br /> ) -, , ,, F. , V 101, <br /> Signed Owner 7 <br /> ---- --------- - -- ---- ---------------- <br /> By ---------------------------- _411� ---------- Title ---------------------------------- --------------------#----------------- <br /> J ------------ _4" <br /> A24 iTZf___ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _------------------------- y -----------------1- 9:7 ----------------------- <br /> 49 ------- DATE - 12�11 6 9 <br /> BUILDING PERMIT ISSUED ------------------------------- -----DATE -------------------------------------------- <br /> ---------- --------------------------------------------------- <br /> --n4ko--------------f---------------------------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------------------ - <br /> I------------------------------------------------------------------------------------ --1_)_1----------- ------- <br /> -------------------------------------------------- <br /> ---------------------------------------- <br /> ------------------------------------------------------------------------------------------------- --------- <br /> ------------------------------------------------------- ------------------------------------------------------ <br /> Final Inspection by: ----------------------------- --- ---------- <br /> 4-0--------------------------------------------------------------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />