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FOR OFFICE USE. <br />. ............................................................. APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No. est <br /> ..................... <br /> ...............I—............... This Permit Expires I Year From Date Issued ©ate Issued <br /> Application Is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described Thi application Is m do ftsypllon a with Count Ordinance No. 549 and exists g.Rules and Regulations, <br /> -275;R Npurg I or, 0 rd <br /> p"4 <br /> J015 ADDRESS/LOCATION ...... Deaf <br /> ..... . .... -? R? <br /> 77F ..............CENSUS T ............ <br /> Owner's Na i?, i M. <br /> .......... tg <br /> Address & no <br /> .... ......... ....... ....... ..... ................ <br /> ........ ... <br /> C", .. . ................ ............................. <br /> Contractor's Nome . <br /> oh. ............. ....... ...... .. <br /> ...............License Phone ... <br /> \�R"cjenk.bb,.Ap Apartment rt <br /> Installation will serve:, 4>1 t House 0 Commercial oTrallor Court <br /> Motel [I Other .............. ......... <br /> _V Garbage.................... <br /> Number of living units ............L Number of bedroollit e....,warogg <br /> a Grinder Lot Size <br /> Public System and name ........... 44 L-j�,7_ .... .. <br /> Water Supply, I � " 4A ,� <br /> . .. ...... ....... ... ................................................................Priya l 0A <br /> Character of soil to a depth of 3 fe t. Sand 0 <br /> S it PeatO Sandy Loam Clay Loom 0 <br /> Hardpan Ltz �_M terial ............ If yes, <br /> (Plot plan., showing size of lot, 16cation of system in relagin to wells, buildings, etc, must be placed, on reverse. side.) <br /> NEW INSTALLATIONS (No septic tank or seepage -pit per Re If public seweris available within 200 feet,). <br /> ,_-PACKAGE TREATMENT SEPTIC TANK-( 4 <br /> ..................... ... <br /> ....................... .: - <br /> Capacity .................... Type' 'No. Compartments ....... <br /> aterial............. <br /> ... ......... <br /> Distance to nearest, Well. ............ ..........Foundation .................... <br /> ..........f.... PropAlne ....................... <br /> LEACHING LINE No. of Lines ........................ Len gtl� f ch 11 <br /> o ra ,line............... ......"" Total Length ........................... <br /> V Box ........ Type Filter Material .....`_.Depth Filter Material ............................ <br /> .............. <br /> Distance to nearest, Well .....................%�% otion .................. Property Line ............... ..... . <br /> SEEPAGE PIT j j Depth A�—- <br /> Diameter ............7.—Number 14* 1�. ........ <br /> ........ .......... Rock Filled Yes No' <br /> Water 7ible Depth ....................... .........................Rock Size ....*........................... <br /> Distance to nearest.. Well ............. <br /> ...........................Foundation ..................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prov. Sanitation Permit .............. ......... Date ,/ Y4 <br /> Septic Tank (Specify Requirements) ............. . <br /> ........ .... <br /> ...................... ......... <br /> 5......... <br /> Disposal Field (Specify Require ants) ........ �Iiw <br /> ._..... <br /> ................................................ ..__...... ....y._........ ...... ./.......... <br /> I................................................... ............................ ....... ......................................... ......... <br /> ..................................1­............................................................................ <br /> (Draw existing and required addition on reverse aldol .......*............... ............ <br /> I hereby certify that I have,prepared this application and that the work will be done In accordance with Son Joaquin <br /> County Ordinanceso,State Laws;-and-Rules and:Regulations rof the San Joaquin Local Health District. Hon* owner or liken- <br /> sed agents signature certifies the following: <br /> "I -certify that in the erformanct of the work for'which this permit Is issued, I shall not employ any person In such manner <br /> as to boco su ar. to ®rkr's Com sats I ot�llfornlo.­ <br /> Signed ............ ............. C. I. ,I r <br /> .. ......... . . Owner <br /> By <br /> " . U . ..... ............................................. Title ......... <br /> (I other than owner) <br /> FO)"EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ............... ................... ........... ...DATE <br /> 4. C17C <br /> BUILDING PERMIT ISSUED ............ _(.... ... .................. <br /> ...... ..............................DATE ....... ......................... <br /> ADDITIONAL COMMENTS ......... ...... ........... ..................... K......I....... ........ <br /> .............................. .................I.................................. ........... ......I................................ <br /> ............I...... ............. ....................... ......... ....... .......................I................ <br /> .......... ................ ........... ......................... ................................. <br /> .............. .......... ...... ..................... ............................... <br /> ......... <br /> Final Inspectionbyt .. ............................ .......... .......................Date ........... <br /> EH 13 2L 1-68 V. _5M I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />