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FOA OFFICE US <br /> APPLICATION FOR 5ANITATION PERMIT. <br /> " Permit No. �_ .1 <br /> .(Complete in 7rfplicate) <br /> This Permit Expires t Year From Date Issued Date Issued <br /> Application is.hereby made to the Son Joaquin Local Health District for c permit to construct and install the work hereln' <br /> described..This application is made in com mance w'th County Ordinance No. 549 and existing Rules and R <br /> � - RP _. p N g egulations <br /> JOB ADDRESS <br /> /EOCATiON .,CENSUS:TRACT <br /> E Owne'r`s Name ..-.._........_.., __..... _. ..Phone <br /> Address._.. .. eft x � City `�. <br /> [,, E <br /> Contractor's Name_,:.. ..._.... � _. ------ 0-10`7.)...............License # ......__... Phone W.6::F4 7_ <br /> fnstollati.on will terve Residence Apartment House❑ Com-nercial'OTraller Court 0 <br /> .......... �^ <br /> Motel El Ot,aer' .......S ' <br /> Number of living. plumber of bedrooms _e3 e Grinder ...._. ..:,_ Lot Size <br /> units__..: <br /> �. <br /> Watet.Supply.. AubiicSystem and name............ -- -- .-- ••...............................................................Private <br /> 3 <br /> Character of soil to a depth of 3feet: Sand❑ Silt Clay 1] Peat l] Sandy Loam ❑ Clay Loam 0 <br /> Hardpan❑ Aiobe� Fill!:4oteriol ...,.....:if yes,type,........... �. <br /> y .. <br /> k <br /> (Plot plan, showing:size of lot, location of sv_•.e:i lir relation to wells, Buildings, etc- must be placed on reverse side.l . <br /> NEW iNSTALLATION: -(No septic tank or seepage pit -3ermitted if public sewer is available within 200 feet,) n v; <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size---.._ _...._.-:-- ------ --------- Liquid Depth„ <br /> �T. <br /> # Capa 'ty Type Material <br /> No. Compartments. <br /> Di,tonce to nearest: Well - Foundation _.._..... <br /> Prop. Line � - <br /> A <br /> LEACHING LINE [ ] Na. of L nes F .............. Length of each line .._ ._... .....,. Total Length .... � <br /> D' Bax ,......., Type Filter Material ._.....Depth Filter Material ...................................... <br /> , <br /> Distcncv t6 nean.s.. Wel! ...... Foundation Property, Lino ......... <br /> SEEPAGE PIT ( I Depth .. .... ...... ..... Diameter ......... Number ...f; Rock Filled . Yes ❑ No C) � <br /> Water Table Depth ...............................................Rack Size .: ...... <br /> Distance to nearest:Well ,.____.. ...._. .. .................Foundation .. Prop. Lina . <br /> REPAIR/ADDITION(?rev. Sanitation Permit `` Date ..) <br /> . Septic Tank (S. e 'i1i.Re uiremcnts <br /> ] . .........._..........—--- <br /> Disposal Ffeid ISTecify Requirements) ...... .: <br /> p..,.. <br /> m-- • ......... ..• •--_... ..... . <br /> (Draw existing and required addition on reverse side) <br /> 1 hershy certify That [ have prepared this application and`that the work will die done in accordance with Sart Joaquin <br /> County.Ordinances, Stote Laws, and Rales and Regulation's of the San .oaquin Local-Health District. Home owner or licen <br /> sed agents signature certifies thi following: <br /> t 'Y certify that in the performance of the work for whlck'this permit is issued,.I shall not employ any person in such manner +=• <br /> as to become subject to Workman's Compensation logs of Cailforni:r." <br /> Signed <br /> _.. .....w. w ) , r <br /> Owner ar <br /> By ..... .. ............. Title <br /> [ifathe 1 <br /> .1er} <br /> �= <br /> a <br /> FOR DEPi.R7MENT USL ONLY <br /> kP1=11CAT10iV ACCEPTED BY.. ' <br /> ............ DATE <br /> 9LIILD;NG PEF11h17 ISSUED ..-.._ r.................... ,.....DATE.... .-......_............................ ' <br /> t ADDITIONA? COMMENTS ? ,7 <br /> } -- <br /> ... f <br /> Final Irsiertianby, ^-. uU- ­ • _------- ................. ate ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> E.FI,9 1=`63 Rev.S.�li <br /> t . <br />