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FOR OFFICE USE, <br /> -41-_'125,:1--- ------- ----, APPLICATION FOR SANITATION PERMIT <br /> -- -------I--------------------------------------I--- y.. (Complete in Triplicate) Permit No_ ___ <br /> ----------------------------------------- <br /> Application is hereby r This /Permit Expires 1 Year From Date Issued Date Issued __,P --- A_ <br /> described. This application hatle to the San Joaquin Local Health District for a permit to construct and in <br /> plicastathe work htlo . is made in compliance with County Ordinance No. 549 and existing Rules anlld Regulationserein. <br /> JOB ADDRESS/LOCAT I---- -- -76 <br /> . . ...... <br /> 16N ------ - ------------- <br /> Owner's Name i� . . CENSUS TRACT <br /> - ------ - <br /> -------------- ------ <br /> ------------ __ - 9 <br /> - —------------- -------- --------- <br /> Address �Fl <br /> --------- -------- L4 A <br /> ----------- --- --------------- City ------ <br /> Contractor's Name <br /> -- --------License, --- Phone 1'eZ <br /> Installation will serve: 01k., ------- <br /> Residence E]Apartme�n4,House,[],!Iomme'rc'!-aI ElTrailer Court :E] <br /> Motel El Other -- -------------- <br /> Number oun <br /> -Garbage Grinder ------------ Lot Size -------- � <br /> f living units:--- Number of bedrooms <br /> Water Supply: Public System and name.q <br /> --- a <br /> ------------------- --1-11 ---j ----- <br /> i1 ----------------------------------------------Private <br /> Character of soil to a depth of 3 feet. Sand'E] Silt i,Cla Y Z1 Peat 0 Sandy Loam E] Clay Loam <br /> ❑ <br /> Hardpan ❑ Adobe <br /> Fill Material ------------ if yes, type..... <br /> ------------------------ <br /> (Plot Plan, showing size_4'-I-6t-location,of system in relation to wells, buildings, etc. must be placed,,on reverse side.) <br /> NEW INSTALLATION: fN6ilseptic tank or seepage pit" permitted if public sewer is available within 200 feet) <br /> PACKAGE 'A <br /> TREATMENT . fillTANK f J <br /> GS6TIC, Size----------- <br /> �Uquid Depth --------------------- <br /> Capcicity" Type -------------------- Material-------- <br /> i I _------------- ------------- N0,. Co'*mpartments _\.......... <br /> Dist. I <br /> nce to neatest: Wel -Foundation ------ Prop. Line ---- ---------- <br /> ------------------------------------- -- ---------- <br /> LEACHING LINE, ]L No. <br /> of.Lines,-_J 'Length of each/ ---------- i ---------- - i Total Length -----------;1 ----------- <br /> V Box --------------Type Filter Material -------------1--l-Depth Filter M6t6ial <br /> 11, (1,1 <br /> \ _J_ F <br /> Distance-to-`nearest: ell—i <br /> ----------------dation Property Line- -------I-----------_-- <br /> Diametet ---- <br /> SEEPAGE PIT De pt' Num6er Rock Filled Yes El No 0 <br /> ------------ <br /> --------------------------- <br /> Water Table,Depth—-------------------------------------- ---1-.Rock-Size-------------- <br /> '11, 41�i <br /> -Distahce to-.n rl, <br /> to -Vell:- ---------- ------Foundation ------------------ Prop. Line ---- -------- ...... <br /> REPAIR/ADDITION(Prev. Sanitation PerrAit <br /> ,4,._� V��Z - -_ Date ---------- <br /> Septic Tank (Specify Requirements) <br /> ------------- ------ <br /> Disposal Field (Specify' --------Requirements} _,/, R ulrements)- <br /> - ------------------- <br /> -------------- <br /> ----- ------------ ---- <br /> ---------------------------- <br /> -----------------------i7:53 1 <br /> ------ --------------------- ------- ----------------------I------------------------ <br /> ------------- -- -------- <br /> - --------- <br /> ------It-------- ---------------- <br /> ----------------------------------------------- ------------------i------ ------/ --I------------------------------------------- <br /> ---------- <br /> (DFaw existing and required additi6n on r6'v6-r'se side) <br /> work w; L. Ari in <br /> I hereby certify thIt I have prepared this application and that the <br /> U es ci; <br /> State Laws, and R and Regulations of the Sci� Joaquin Local Health,ilth District. Home owner or licen- <br /> sed <br /> Ordinances,' State accordance with San Joaquin <br /> .f. <br /> sed agents signature certifies-the following: <br /> C <br /> "I certify that in the perfo ..K. - <br /> - <br /> rmance of the work for which this permit is issued, I shall not m <br /> as to become subject to Work'man's CorripensZifion law' of California." employ any person in such manner <br /> Signed---------- --------------0 <br /> -------------•---- - Owner <br /> By ----------- I <br /> ----- -- -- ----- -- <br /> - ------ ------------------------ --------- ---- -- <br /> (if other t owner) '�J Title I L -------- ---- -------------4----------- ------------- <br /> FOR DEPARTMENT USE' ONLY <br /> APPLICATION ACCEPTED BY _IM____- 0-4b-'_ -1 1 <br /> BUILDING PERMIT-ISS-ED- ioA.(-------------- ----- --------------------------------- DAT <br /> ---------------------------------------------------- <br /> ADDITIONAL COMMENTS":_____I� -------------------------------- - ------- <br /> -------DATE'-------------------------1 <br /> ---------------_c--------------- --------------------I--------------------------------- <br /> -------------------------------------------------!�----------- --------------- i ------------------------------------------------------------- <br /> ---------------I------------- --------------------------------------_---------------- <br /> ----------------------------;------------------I----- ------ - ---------------t 0 ---- <br /> ----------------- ---------------------- <br /> --------- <br /> ------------------------- ----------------------- i�, i --- ---- ---- <br /> -----V� \ --------------------------------------------------------- -- <br /> Final ---------- 'A �"L %_�k k 'L-'__�L­ I <br /> 1�-------- --- -----=-=------------------------------------------- <br /> f <br /> --- ------------------------------------------------- <br /> Final Inspection by: --------------------I----- _V _6__�----- ---- <br /> ----------------- - — a- - <br /> lr_�---------------------11--------------------------------.-Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />