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FOR OFFICE USE: <br /> Datr>; Issued <br /> ------ ...................... .......... APPLICATION FOR SANITATION PERMIT <br /> ........ .....................I.............................. (Cctvrpletsgn Triplicate) Permit No. <br /> .................._._................................ This Permit Expires I Year from Date issued <br /> Application is hereby made to the i Son Joaquin Local Health District for a permit to construct and Install the work herein <br /> described. This application is mode in compliance with County Ordinance.No. 549 and <br /> existing Rules and Regulations- <br /> JOB ADDRESS/LOCATION <br /> ------- .... ......ROO <br /> Owner's Name ----------0)DII,LE................­.......................CENSUS TRACT ........ ................. <br /> --'-\/...................Phone ......... ....................... <br /> Address ..........!1,V/.,/-..........._&aal IQ I)AL_F_ /9)71e; <br /> .............................0.............City ............. ..................... <br /> Contractor's Name -------77_4��:� 114_� 6.�- 4 <br /> Ai t <br /> ...............................License # ...r................ .... Phone .................... <br /> Installation will serve: Residence[I Apartment House 0 <br /> — Commercial oTroller Court 0 <br /> Motel 0 Other <br /> Number of living units.-.5...... Niii-riber of beclrooms�-o------Garbage Grinder ........._ Lot Size ...... <br /> Water Supply.. Public System and name .... <br /> t .............................. <br /> ----------------------............................................}-...._Private.. 0 <br /> Character of soil to a depth of 3 fee I t: Sand E]. silt 0 CIQYEJ Peato Sandy Loam o Clay Loam c] <br /> Hardpan 0 Adobe 0 Fill M6terIol ......... <br /> ... if yet,type............... ............ <br /> (Plot plan, showing size of lot, location of system In relation to wells, etc. must-'be placid on reverse�rse side.) <br /> NEW INSTALLATION: (No septic lank or seepage pit permitted If public sewer Is available within 20.0.'feet,) <br /> PACKAGE TREATIArLIV' jj I <br /> SEPTIC TANK <br /> CapacityMateria.----_-... <br /> .................... •-- •-- Liquid •Depth ........................... <br /> ------ ...........­ Type --------- ---------- Material............. `Compartments ...................... <br /> Distance.to nearest: Well ......�Founclatlon . .................... Pro�. line ...................... <br /> 1 4 > <br /> LEACHING LINE No. of Lines ..........10............. Leng-t-6-,64'-edch line..................... <br /> ...... Ti�tol Length -......................... <br /> V Box ------- Type Filter . aterioll <br /> :.Depth Filter Material ....... <br /> Distance to.nearest, Wel .....--- U <br /> SEEPAGE Depth ------ I .. - Foundation nclation -------_----I: ...... Property Line ................. <br /> y <br /> Filter I <br /> e <br /> e <br /> r <br /> E PIT Diam er ----------_--- Number .................. ..... ... Rock Filled Yes [I No C) <br /> Water Table Depth <br /> - --- ------------------­--- ........�:Rock Sizi.: ! <br /> Distance to 'nearest.. Well - - ---------­- ...................Founclotion7 <br /> ..... Prop. Line ...................... <br /> REPAIR/ADDITION(P• rev. Sanitation Permit ......... •. ......_ ---w- - ). �. <br /> ... ................... Dote� ........ <br /> ............ <br /> Septic Tank (Specify Requirements) -----------­------ .............. <br /> ................ ..............:­.......... <br /> --­-------- ................. <br /> ----- -------- <br /> Disposal Field (Specify Requirements) ---- .......1Z0q........".it.ow. . <br /> ... <br /> 5F_Frc-�;----T1.16JI41 6W EF&,6------77�9 <br /> P" T�!.._ORR <br /> APP <br /> (Draw existing-and-required addition-,on reverse sid0)---* A...... ....... <br /> Z"A r,;�� <br /> I hereby certify that I have prepared this application and that the work Will be done in,accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of-the,Sn Joaquin Local Heal&District.'Home owner or 1111cen- <br /> zed agents signature certifies the folliwing: <br /> I certify that in the performance of the" work for which this permit is issued, I shall not employ a"y person In such manner- <br /> as to become subject to Workman's CoApensation laws of California." <br /> Signed , 7 - <br /> -----T�_,a�, - <br /> ----•--------------------•-------- ... Owner <br /> By ..... I <br /> .......... <br /> ------------------- ------------------------------------------ Title ............... <br /> (If other than owned ......... .......... ............... <br /> FORD PARTMENT USE ONLY <br /> APPLICATION ACCEPT <br /> BUILDING PERMIT ISSUED ----------- ...... <br /> .....................................•------------...-----.--... ---DATE ..._-_............ <br /> ADDITIONAL COMMENTS ----- ----------------- =i - � �1'_ <br /> ...... ......... ---------------------- --------------------------------- ................ <br /> -------------- -----­---------------------- --------­-------------­ ......... <br /> ---------- ------------------------------- --- ----------­-----------1-1----------- ------------------------------------------ ................ <br /> ----------- ---------­------- ----------------I-------------- ---------- ------------- __----•--------•-------------- ......................................... <br /> Fina! Inspection by .. <br /> -------------------------•----------.._---•--------------- ------------------------------ <br /> ------- --------------- _---------- .Date <br /> EH 13 2h 1-68 Rev. 01 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 31K <br />