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FOR OFFICE USE: i FOR OFFICE USE, <br /> APPLICATION FOR SANITATION PERMIT <br /> lCompleto in Triplicate) Permit No. .�..... ... .. ... <br /> This Permit Expires 1 Year From Dot*Issued II Date Issued / <br /> L� <br /> pplicati-)n is hereby made to "ie San Joaquin Local Health District for a permit to construct and Install the work herein described. <br />"is app!:-otion is made in r,,mpliance with County Ordinance No. 549 and existing Rules and Regulations, i <br /> ' . . .. .O.-.466' <br /> , o.CENSUS TRACT.......... . .....DB ADDRES:!ICCATION ."/� 14,1, I <br />)wner's Name Li, „p ,/P.ec hone <br />.ddress .762 <br /> ty.. tee+.!..... ... Zip............ <br />:ontractor's Name. cc .license #. .... .... ........ . Phone .................. .. . I <br /> tstollation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ ` <br /> Motel [:] Othe; .... ................ a <br />!umber of living units: . ..... Number of bedrooms Garbage Grinder............Lot Size....... <br /> later Supply: Public System and name .......... ....... .............. .............Private ❑ <br /> haracter of soil to a depth of 3 feet: Sc,nd _ Silt ❑ Clay❑ Peat C] Sandy loam❑ Clay Loam ❑ <br /> Hardpan [J Aciobe ;] Fill Material If yes,type.... ....... .... .. <br />'tot plan, showing size of lot, location of system in relation to wells, buildings,etc, must be plac••d on reverse side.) <br /> EW INSTALLATION: (No septic tu„k or seepage pit permitted if public sewer is available within 200 feet,) <br /> ACKAGE TREATMENT ( J SEPTIC TANK ( j Size . . liquid Depth .... . ._ . ..... �` <br /> Capacity Type .. Moteriol . .... .. .... .. ..No. Compartments ...... . <br /> Distance to nearest Well _ . —Foundation .... Prop. Line ... . . -.. ._ .. <br /> :ACHING LINE ( J No, of Lines .. length of each line . . . .. ... . Total Length ........... <br /> 'D' Box Type Filter Material . Depth Filter Material.. .......... . ... ............. ....... <br /> Distance to nearest: Well Foundation.... . ............... Property Line .......... . <br /> :EPAGE PIT ( j Depth Diameter Number ....... Rock Filled Yes❑ No❑ <br /> Water Table Depth ,.,......Rock Size.. <br /> Distance to neurest Well ....Foundation . Prop. Line <br /> :PA!P./ADDITION (Prev. Sanitation Permit / -.. / _..Dote . .. ) <br /> optic Tank (Specify Requirements) 51;e,* h-�� �C.c`�'���� �. ... 7411✓ �. <br /> np)sal Field (Specify Requirements) <br /> (Dru,Y existing and required addition on reverse side( <br /> hereby certify that I have prepared this application and that the work will be done In accordance with Son Joaquin County <br /> rdinances, State Laws, and Rules and Regulotiens of the San Joaquin Local Health District. Home owner or licensed agents <br /> gnature certifies the following: <br /> certify that in the performance of the work for which this permit Is issued, 1 sholl not employ any person In such manner as <br /> becor�iet to W(orkma��ompensoNon lows of California." <br /> gned «'ECJ L"fel`' Owner <br /> y Title <br /> (lf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY f'Qom.-- DATE -.7.71�0'' <br /> IVISION OF LAND NUMBER DATE <br /> DDITIONAL COMMENTS <br /> - ./ � ... . . Dote <br /> nal Inspection by <br /> ,,'l JOAQUIN LOCAL HEALTH DISTRICT EXHIBIT A •• 1 0f '2 <br />