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FGR OFFICE USE: r <br /> APPLICATION FOR SANITATION PERMIT V <br /> .................................................. =� Permit No. 7ff7:!o h' <br /> In Triplicate) <br /> v <br /> (Complete P - Date Issued j *, .-,7g <br /> This Permit Expires t Year From Onto 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 inqe,Jn compliance with County Ordinance No. 549'ond existing Rules and Regulationst <br /> 1,96's <br /> JOB ADDRESS/LOCATI N .... r ►.�t�1. .._.....- _..{_.........CENSUS TRACE .. .�-.............. <br /> Owner's Name ..//. - - ....................•--------- ••............... .... ..-..Phone .t Y�6..� ..1�........... <br /> Address ... =f (pfccz..= ----- .............................. City ..-. <br /> Contractor's Name --Win.------- --- ---------•--- ---------------------------------------eicetise <br /> --- ----------------------•••--••----eicersse # -Alof.... ............ Phone .Z*f_4550L -•_.... <br /> Installation will serve: Residence❑Apartment House 0 Commercial OTraller Court 0 <br /> Motel other <br /> Number of living units.-.-/...... Number of bedrooms ____ --- Grinder _YDS.__ Lot Size .__.__ - <br /> jv4 <br /> Water Supply: Public System and name -------------------------------= �, Private r ti <br /> I Al �, 4w I <br /> Character of soil to a depth of 3 feet: Sand❑ Silt o Clay .0�:Peot 0 Sandy Loam ❑ Clay Loam . <br /> f Hardpan Adobe p fill Material ,........-- If yes,type ............... ...... <br /> a.... [' <br /> r E . e <br /> (Plot plan, showing size of lot, location of system in relation to w tis, buildings, etc. must be', laced on.reverse side.?' <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if .public sewer is available within 200 feet] I <br /> PACKAGE TREATMENT [ SEPTIC TANK f I Size................. . ............... -•_. Liquid .Depth !........................ <br /> ~' _ No. Com artments ---. -••-• =� <br /> Capacity ----` yp �a... erial- I FT <br /> r . • ........' <br /> 'Distance to, nearest: Well ----------- �� �:._. Prop, Line �......_ Iv <br /> LEACHING LINE [ j No, of lutes ____.a�•_.__ Length of each line.._-:--t� Total Length <br /> O <br /> 4 'D' Box ... QS. Type Filter Material f/.{-S!. _Depth Filter Material �� 'F <br /> Distance to nearest: Well ...... ....... Foundation .....✓�7�T...... Property Line <br /> SEEPAGE PIT ( ] Depth ----cAS._-._ . Diameter 33�.`-'-.--- Number ............0................. Rock Filled Yes 59 : No <br /> ' �. 0 <br /> Water Table Depth ------------ -- -Q�¢'.-•-----....--•............ Sire <br /> Y r J� <br /> - Distance to nearest: Well .. .. fid '"'................Foundation ..../A.'a. f T•-Prop. Llne <br /> ,17 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------- Date .........________........._....... <br /> � <br /> F Septic Tank (Specify Requirements 'r <br /> Disposal Field ISpecIfy Requirements) --------------------------------- ------- <br /> ------------- ---------------•------------------- -------- ----------•----•----------------------------------------------•--'----•----- ......._.......--•---. •-•--• <br /> 1 <br /> 1 ----- -----•--- ........... l................. <br /> (Draw existing crud required addition on reverse sides '; --- ---; <br /> 1 hereby certify that I have.prepared this 'application 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;Heaith District:Home owner or licen- <br /> sed agents signature certifies the following:, ' <br /> "I certify that in the performance of the work'for which this permit is issued, l"sha11 not empl y ny person in such manner <br /> as to becorn suWed to W kman's ompensation laws of California."4,.,'r <br /> � � �" <br /> Signed � p <br /> € s <br /> BY ..............................................................ther than ownowner) <br /> (If othe ..........••--••--------...•.................................. - Title ..------- - .�.---------------- <br /> ' _ <br /> I FOR .DEP R NT USE ONLY f <br /> APPLICATION ACCEPTED BY ....- . ..... -------- ...................DATE .9f/7-•9q <br /> BUILDING PERMIT ISSUED _... ---•----- ----- •--- .. 7------------- <br /> BUILDING <br /> -••-- - '--- <br /> - •� ----------------DATE - ---------..__..........-------------.._. <br /> ADDITIONAL CQMMENTS . �- <br /> ---------------------------------------------------------------------------------------- --------•--- ........... <br /> ------------------ ----------------------------------- ------------=--------------------------- ----- ••----. ---------------- --------------- ---------------- <br /> -- - <br /> Final Inspec ------- ---- <br /> tion by: . <br /> Date ... <br /> lH 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />