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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 71- 33(l <br /> Permit No-. '---- --••-. <br /> ------ <br /> ----------- <br /> ------I-------*---------------------------------- (Complete in Triplicate) I <br /> r. --------------------------------------- Date Issued ._--:-`.^-... <br /> --------------------------------------------------------- <br /> This Permit Expires I Year From Date Issued <br /> Application isA-ejreb,�made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with Couniy Ordinance N 0. 549 and existing Rules and Regulations: <br /> __1 ACT <br /> 2-0- - . <br /> f— --------------------------CENSUS TR <br /> �ATION ---- <br /> JOB ADDRESS/LOC A)A---- <br /> Phone --------------------------- <br /> Owner's Name ------- _)A- --- ---------- <br /> Address --- --- ------- 'Q -----• -_ city -------- ---------------------------------- <br /> -- -----;1--------CIZ ----- <br /> Contractor's Name -------------------------------------/---------- ,r---,----License* ---------I---------------; Phone -------------------- --------- <br /> v �nTraile;r Court <br /> Installation will serve- Residence Zg-A`p5rtment Yiouse°E] Commercial <br /> Motel gjdrooms <br /> 6ther ---- -------------------- --------- <br /> -1j - - <br /> _�_ _..Garbage Gi11im1berofrinde �_ Lot Size -A(R-4. Number of living units:----- ----- <br /> Water Supply- Public System and name ----------------- -- ------- ------------------- ---------,Private- <br /> -----------•------------------ <br /> X y ,[j (,— <br /> Character of soil to a depth of 3 feet: Sand'O/Silt Clay [I peat SandLoom ClayLoom El <br /> 1_� a NIS <br /> Har,d.p,6n E] Ad'pbe E] Fill Material Mij- if yes,type --- <br /> buildihgs, etc. must be placed on reverse side.) <br /> (Plot plan, showing size of lot,11ocation.of system in relation to wells, I .1� U. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer.is available with#n <br /> in 200 feet,)I I TANK'[ ] Size -- <br /> ----------- --- ---- ------- :------------------- Liquid Depth -------------------------- <br /> PACKAGE TREATMENT <br /> SII <br /> I " ------------ N Compartments ----�_­­ ............ <br /> Capacity -------------------- Type ------------ <br /> ------- Material------------ <br /> -riclation --------- -----------.Prop. Line ----------------_---- <br /> Distance to nearest: Well - ------------- --------------------Fou I <br /> ------ Length of each,line---- ------------------ Total Length ------------ - ----...------- <br /> LEACHING LINE No. of Lines ----------------------- <br /> V BoA Iter aterial -------- _2 ..Depth' Filter Mat rias --------------- ................. <br /> Boxl_.___.------ Type Filter Mat <br /> ---- -- -- Property Line. ---------------I........ <br /> ---------- Foundation -----�J�--- <br /> Distance to nearest: Well -------------- s ❑ No <br /> I Diame,er ---------------- Number ------------------------- --- Rock Filled Ye [1 0 <br /> SEEPAGE PIT Depth ------------------ e. <br /> - <br /> ----------Rock Size ----------- -------------------- <br /> a <br /> M <br /> Water Table Depth ------------ ------------------------- <br /> Distance to nearest. Well -------- 4--------- Foundation ------ -- ------4Prop.' Line _..__..•.•.--..•----- <br /> ---- ------------ <br /> _rm ------- <br /> REPAIVADDITION(Prov. Sanitation Pe it,.# }t <br /> -------------------------------------- <br /> Septic Tank (Specify Requirements) ------------------------------- -- ------ - ------------ --------------- <br /> a----------- ------------ <br /> ------AM---------ji-AW------------ <br /> Disposal Field (Specify Requirements) <br /> ---------------- ---------- -------- ------------------ --------------- <br /> __A=_XV$T1_ --- <br /> ----------------------------- <br /> ------------------------------------ ---------- -------------------------------------------------- <br /> -------------L-------------------------- ---- ------------------------ d required addition on reverse side) <br /> -) � --i , (Draw existing an req accordance with San Joaquin <br /> hat 'l have prepared this application and that the work will be done in <br /> I hereby certify I - of the Son Joaquin Local Health DisWict. Home owner or licen- <br /> County Ordinances, State Laws, and Rules and Regulations a, <br /> sed agents signature certifieiA6 following: <br /> "I certi in the perfo c of the work for which this permit is:issued, I shall not employ any person in such manner <br /> as to bec subject <br /> t m s Compensation laws of California." <br /> Signed --------------------------------------- Owner <br /> ---mk-��_gp Title - ------------- ----------------------------------------------- <br /> • <br /> By ---------------------------------------- --------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE I ------- __7n__7=_-7-- ---- <br /> APPLICATION ACCEPTED By -—-------- --0--60 ,- <br /> W DATE- m--------------- <br /> ----------- <br /> pa-T ---I-N-------- ------- <br /> BUILDING- PERMIT—ISSUED--n __n---- <br /> ADDITIONAL COMMENTS --- -------- <br /> ---- -------------- ------------- -------- <br /> ------------------ ------------ ------------------------- <br /> ---- ----------------- ------- - ------ ----------------- ------- ------ <br /> ---- ------- --- ----- - ----- <br /> ---- -- --- - -- ---- --- ---- -- --- ----- -- <br /> ------------ -7 - <br /> -------- 1�:�7 f Date - <br /> Final Inspe t <br /> nSDe <br /> SAN JOAQUIN LOCAL HEALTH':;DISTRICT,- <br /> _-68 Rev. 5M <br /> F. H. 9t i <br />