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FOR vfsFlc.E [tSI:: APPLT,,tATION FOR SANITATION PERMIT I <br /> ..................................................... hermit I\io. 7S� ys <br /> (Complete In Triplicate) SJ <br /> ..................................... Date sued 7-.7—..7S <br /> ..... This Permit Expires F Year From Date Issued <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> described. This application Is made in compliance with County Ordinance No. 549 and existing Rules and Regutations: <br /> JOB ADDRESSAOCATION � 1 11-,1 . �......P.Y�Y....?73-.-:-:.:..........................CENSUS TRACT ......Sr�..- <br /> Owner's Name QHN Ray.?!S= ................................ -•-••..............Phone .................................... <br /> Address ..X4 1V 1.F... ami O uNTR ....... . f�� City. + .................................................. <br /> Conti' 1 N iid = ; / <br /> actor s Name . .... .I.............•--License # ........................ Phone .............................. <br /> installation will serves Residence a Apartment House Commercial❑Trailer Court 0 <br /> Motel []Other <br /> Number of living units:.... .... Number-of bedrooms ­9:=Garbage Garbage Grinde --, Lot Size :.............---` <br /> Water Supply: Public System and name .................................w----------••- - •----------.-.-.._.........._........private <br /> C dracter of soiljto a depth of 3 feet: Sand o Slit❑ Clay ❑ Peat❑ Sandy Loam o Clay LoomJey", <br /> Hardpan ❑ Adobe❑ Fill M6#erial ............ if yes,type............... ............ <br /> (Plot plan, showing size oflot, location-wof`systerri-ln�re(atia`n to wells, buildings, etc. must be placed on reverse sld <br /> 6 <br /> NEW iNSTAlU1TIONr No septic #snit orseepapit permitted if public sewer is available within 200 feet,) . tr <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:{ Slze... .::� Liquid Depth .. ..._.,..... <br /> Capacity _/V ,__ Type.PR Material. No. Camdartments ..��. ....... <br /> Distance to nearest: Well' Q ................Foundation -I ... :... Prop. Line ....6............ <br /> .EACHING LINE a, No. of Lines .......rLength of each line.-.-...Q......... ... Total length ..141............. <br /> 'D' Boxx—r,�. Type Fitter llllaterial .� �C' ..Depth Filter Materlal .... ............. <br /> Distance to nearest: Well Foundation ....... Property Line .S..... .N <br /> SEEPAGE PIT [ g Depth -- Diameter ..........I.... Number .......... Rock Filled Yes ❑ No "W' <br /> Water Table Depth ...... :.......................................Rock Size ......'.i. ......... <br /> Distance to nearest: Well .Foundation <br /> ...................................... 3' Prop Line .......,.----­----- <br /> REPAIR/ADDITION(Prov. Sanitation Permit ........... Date I <br /> SepticTank (Specify Requirements) ......................................•-- -----•-----..._................. .- -.,........,_. ..........._................ <br /> Disoosal Field (Specify Requirements) ...................................•---................_........................ .-----•---•--•---•----•-----••-...... <br /> �. <br /> ------------------.....................................................................................................................i.S...._.-........... ................................... <br /> ........---•....................................•-.................................... .......... ......................I......... ................................................I........ I <br /> (Draw existing and required addition on reverse side) , <br /> I hereby certify that I have prepared this application and that the work will be doWo In accerdance with San Jooquln- <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hoene owner or llcen- <br /> ied agents_stgnature certifies the following: <br /> "I.certify i in-th _perform ce of the srk for which this permit Is Issued, 1 shall noll'employ any person In such manner <br /> as to bel a su t-66 W an' s a allfornia." <br /> Signed .... . _ ... Owner <br /> ... ... <br /> - ` <br /> (If other than owner) '�-.........•` �-::�-~''�_ <br /> :. i � ~� <br /> FOR�DEPAItTMfNT USE ONLY ' <br /> APPLICATION ACCEPTED BY E- `— .., DATE ....77 `. <br /> BUILDING PERMIT ISSUED •_ .........................DATES ..-.---.............. <br /> ADDITIONALCOMMENTS ... ......---•.............•---..._..... •-- -------------.......--------..-....---..............-..........................:------ ----..-.-... <br /> . ... .. .... ......................... . ........ .....••. . •. ---- ...-.......----... .................... ---.................-- .......... <br /> _.. ... - --- .. <br /> .............. ... <br /> Final Inspection Date .. .... ....-...... <br /> L14 13 2h 1`68 ltov• SAN JOAQOIN LOCAL HEALTH DISTRICT 8/7h 3M <br />