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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PER)LqT <br /> ------------­-------------------------------------------- n Permit No,. <br /> (Complete in TriplicatO, <br /> ----------I-------------- ------------------------------ <br /> Date Issued M1 1 Year From'baie Issued <br /> ------------------------------------------------------ A This.Per "t Expires <br /> App ' n is hereby made to the San-Joaquin tociatkealth Disirict for aj per Mit to construct and install the work herein <br /> described.cr�icbat�oed. This application is'made-incompliance with Count,/ OrdinanceNo'-..,g549; and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -3- --------F__ rj V ------i--------CENSUS TRACT ------ <br /> ----------A V---------------- <br /> Owner's Name ---------------- XF—L.4�F-F---------------------------------------�L------------- ------ Phone ...... <br /> ------------ -------- <br /> Address ------------- -- --------- ------ city ------------------------------------------------- <br /> Contractor's Name ----0Wt4r=_7R-----------------------------------------7- ----------------------Li.cense # -------------- Phone -------------_--------------- <br /> Installation,will serve: Residence,[]Apartment Hous:eO Conv'Tiercial :E]Trail&Court 0 <br /> Motel E]Other ------------------------------------ <br /> L" Size, l-'ell------- <br /> Number of living units----- .......Number of bedrooms ---3_____Garbc!ge Grinder Ot <br /> Water Supply: Public Systern and name ........_--------••-•-----------•---------------------='- ------ -------------------------------------Private H__ <br /> Character of soil to a depth of 3 feei: - Sand'E] Silt C] Clay FPeat❑ Sa.ndLDO m e: Cl ay Loam 0 <br /> 4 <br /> I <br /> f <br /> -.,Hardpan D I ate y ty --------- ------ <br /> ps, <br /> Adobe 0 Fill M ril pe ----------- <br /> (Plot plan, showing size of lot.:location of systern in relation to wells,�b-uildings, �pljc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septicJi6nk or seepage.-pit public sewer is available within 200 feet) <br /> .. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Imo' 'Siid 777'- ----: <br /> Llcui'j' DeF <br /> tl; " z-'--------•-- <br /> Capacity • <br /> - ----c6pacity Type fib--- Material' Na. Compartments ....................... <br /> Distance to nearest. We'll ------------------ /100__--- t..!F6vnclatibn-�..... --°_;---- Prop. Line ......... <br /> 0 N Tot6l Length ....... <br /> LEACHING LINE of ------------------ ----- Lengt of'66ch r 1; N <br /> 5�1 <br /> D Boxe5_ Type Filter Material POICK-L-bepth Filter;� Material ---------- <br /> 7.11" <br /> Distance to nearest: Well ------- Foundation ------- ------ Property Line ------ ........... <br /> SEEPAGE PIT [kTDe Diameter Number ------------------- -------- Rock Filled Yes No El <br /> pth. <br /> ----------- 'Rock Size" <br /> 'Table Dept, ..... <br /> Water <br /> X/ <br /> , h ------------ ------ <br /> istance tc�,ne arest <br /> Di Well _.----------- -------------- ....... <br /> _"F`.---Foundation .....-o�� ------ Prop. Line <br /> REPAIIR/ADDITIIONL(PreV. Sanitation Permit ---------­--------- <br /> -------------- ------ Date ----------------------------------) <br /> Septic <br /> ---------- --------------- <br /> Septic Tank (Specify Requiremehfi)--, ----------------­------------ ­----------- ....... <br /> -------------------------------------------------------7­ <br /> Disposal Field (Specify L.Requirements) __.--------------------------------------I--------------- m------------------- ------------------------------------- <br /> ------•-------------------------•-------- -------------•--------------------------------------------- - ----------- -_--- ---------•--------------------- 1 --------------- <br /> ----------------------------------------------I------------------------------------------------------ --------- -------------- ---- ---------------------------------------- ------- <br /> ,113raw existing and required addition 6ik reverse'sijt <br /> I hereby certify that I have prepared this application and that the work will be' 'done,in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules.and R69ulationslbf the Son Joaquin Local Health District. Home *W-nor or licen- <br /> sed agents signaty 'certifies the follow <br /> �e ihg: <br /> "I certify that in the performance of 146e.work for which this p ermit1s.1ssuiW,,1-shall not employ any person. in'suich manner <br /> as to become s6biect to Workman's,Compens ion laws of California." <br /> 0 <br /> Signed ----------------- --------------------------------------------- Own6r, <br /> By --------------------------------------------------------r--------------------- - . . ....... Title <br /> ------------------------------------------------------------------ <br /> (if other than owner) <br /> FOR DEPARTMENT USE-ONLY <br /> APPLICATION ACCEPTED BY -----T__t.R__Z�----------------------------------------- - ----------- <br /> ---------- ----------- --------- <br /> BUILDING- PERMIT ISSUED ---------- -- ----- --- --::"-,DATE ----------- ------------ --------- <br /> ----- ---------- A --------- <br /> ADDITIONAL,COMMENTS <br /> - --------------- <br /> -------------------------------- - ----- - ---- --- ---- <br /> ..... .... --- -------- --------------------------------------------------- <br /> --------------------------- <br /> - ----- - ---- ---- -------- ---------- ------- <br /> ---------- - ------------- ---------- -- -------- ---- ---- -- --- --- - -- --------------------------------------------- ----------- <br /> Finol li-ispe b ----------------------------------------------------Date -V--------- <br /> ------- <br /> 'SP <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'66 Rev. 5M <br />