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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> t�.-'77 —11 Permit No,. 4,1,9--l-011 <br /> (Complete in Triplicate) <br /> ----------- ------- ----------- -------------------------- <br /> 9 Year From Date Issued Date Issued <br /> 4 This Permit Expires I <br /> Application is hereby made to the San Joaquin Local Health District for a per'mit to construct and install the work herein <br /> described. This application is made in compli nce with County Ordinance No. 549 and existing Rules and Regulations: <br /> County <br /> ----------- <br /> JOB ADDRESS/1-OCATIO�L_­ --- --------- - - -----------------------------------------------------CENSUS TRACT -------- <br /> 1 :14.M40/J------------ -------- <br /> Owner's Name ----- ------ ---- --- --------------------------I-------------------Phone <br /> Address --------------VP------M-4 4 . 4 _p *68 ---------------------------- -----4--- <br /> City <br /> ---------- <br /> Contractor's NameT*�4.P4---11_6_,h_RA9------ie- <br /> ------------------I-----------Licen se # J ---- Phone ----------- <br /> Installation will serve: Residence [!Mpartment House[I Commercial :E]Tra i ler Court ,E] <br /> Motel ❑ Other ----------------- ----------------- -------- <br /> Number of living units:---.1---.-- Number of bedrooms -------Garbage Grinder Lot Size ----------------- <br /> Water Supply: Public System and name -------Z _4 --------------- ------•--------'-------------------------------------------- ------Private El <br /> Character of soil to a depth of 3 feet: Sairid'E] Silt[] Clay ❑ Peat[I Scfridy L6d(n-0— 1 Clay Loam.F] <br /> Hardpan M Ad:obe [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 it permitted i public.s4p)keris available within 200 feet, it <br /> )----SEPTIC TANK:[ Si x 11 'F _:r----- T\ <br /> PACKAGE TREATMENT, (i k 11-��'r <br /> ­ <br /> ze---I-A-4 2 ---------- Liquid-Depth ---- ------ <br /> o. Compartm <br /> a" iCapatity,4406------ Type 0-M!;------- Materfal-A-31-t-_ N erits ..... 1�4 <br /> ne <br /> Distance to nearest: Well --------Foundation ------------- Prop. Li S--_-------- <br /> LEACHING LINE No. of. Lines -----_Z-------------------------- Length of %choline -_76---------------- Total Length .------ --------- <br /> 6� to - <br /> 'D' Box ----- Type Filter Material Depth Filter Material ----_---------------- <br /> 11 It <br /> /,Distance to nearest: Well ---NON-R----Foundation-6 ------�P- ------—Property Line- ------6---------------- <br /> . , I Depth --- /Diameter ------------- lumber ----------2-------------- Rock'tilled Yes OR-` No 0 <br /> SEEPAGE PIT <br /> Water --------------­-- <br /> Table Depth --------2,-_Cr--------------------------_.Rock Size..........V #0 1 1 <br /> Distance to nearest: Well ----- Ar-----------------Foundation ----i p--------- Prop. Line --_--.$-__._...._. <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ----------------_--_-- ---------------------- Date --------!1------------------------- <br /> Requirements) ---------------------------------------------------------------------- ------------------------------ ---------------------------- <br /> Septic Tank (Specify Y <br /> DisposalField (Speeify Requirements)--:------------------------ ---------------------------------------- ------------------------------------------------- --------------- <br /> ------------------------------------------------------------------- <br /> --------------------------------- ----------------------------------------------------------------------------------- <br /> -------- ---- -- - - - - - ------------- ---- <br /> Draw existing and required addition on reverse side} <br /> 4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> i ', f 4' <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents'lig nature certifies the following: <br /> "I certify that in the pe'rFormance of the work for which this'permit is issued, I shall not employ any person in such manner <br /> as to becom �Vect Work ri's �d' <br /> ation laws of California." <br /> Signed ... --- --- ----------- - ------- o------------------ --- Owner <br /> .......... <br /> By ---------- _------------------------ --- --------------------5------------------------------------------ Title .-------------------- -------------------------------------------------- <br /> (If other than owner) <br /> FOR .DEPARTMENT'USE ONLY <br /> APPLICATI BY ------- DATE ---------- 4_3--------- <br /> LPN,ACCEPTED --- ---------- --------------------------------------------:-------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALSOMMENTS --------------- -------------2----•---------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------L�_'V---------------------------- ---------------------------------------------------------------I----------------- ----------­­­---- <br /> ---------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------- ---------------------------------------- <br /> --- -------J� ----------Z/--'A-2 ­�_ -­ <br /> ---------------------------- ------------------------ ---------------------13----------------- <br /> Date --- <br /> Final Inspection by: ----- - - -------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M. <br />