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Folz©FFIcF t,si: <br /> y ,� ? APPLICATION FOR. SANITATION PERMIT <br /> IComptetw in Triplicate! Permit No. ._-.7 9­ <br /> .................................... <br /> ­ ' <br />' .........:,..•:.: . .........._ :.... This Pennitl:x fres 1 Y .... Date lssued�. //-..761 <br /> . p Year from Date issued <br /> Application Is hereby made to the'Son Joaquin local Health District for a permit to construct and install the work herein <br /> dos uibeId. This application Is made in <br /> compliance with County Ordinance No. 549 and existing Rules and Regulationse <br /> JOB ADDRESS/LOCATION .r- .! .aG�f .. �.` - ................ <br />. -......CENSUS TRACT ....................... <br /> Owner's Name ... .... rs Q,:r ,......:.... ................................Phone �h...... . <br /> Address .... ............... .........................`Ci .. ...©.. . . <br /> Contractor's Name ...! �.4?. ...................................license # ....... , .._.......... Phone .. 66_... <br /> . .1 ....,Z... <br /> Installation will serve: Residence hLApartment Housefl Commercial❑frailer Court <br /> 13. <br /> Motel❑Other... .......... ..................... <br /> Number of living unite,_1....... Number of bedrooms ...2—....Gar• e Grinder Sian ................................... <br /> Water Supply: Public System and name _ <br /> . ..._..... ................... •.... <br /> .Pfiwrfe Q. <br /> Character of soli to a depth of 3 feet: Sand❑ Silt❑- Clay ❑ Feat Loam <br /> . . ❑ �Y Ll pay Loom(� <br /> .Hardpan❑ Adob°p '1111 Material- .if yes,type. ..........:.. ..........:. <br /> ti <br /> )Plot plan, showing size1of -lott, location of system in nlotionr�ta wells, buildings, etc.- nwst be placed on reverse swo.1 <br /> NEW1NSTAtlATIl2N: (No'septic tank or seepage pit pwr ifted,iif publk sewer is available within 200 feet,) <br /> PACKAGE TREA <br /> TMENT '( �SEPTJCTANK . ' <br /> � 4 .....:.... ......... Uq%" Depth ........................... <br /> Capacity t.2�. pe,. �;e �.J .... AAaterlal .�.tr.�. s. No. Com ....� .......� <br /> Dist",.tom nearest: We11 .. .... .V�..T.�..-f.�..Foundation ..... <br /> � .isrop, Lim. �?...f.. ` <br /> LEACHING LINE ,p j No. of li�i---�.- . -� �Le Chia elach line",��r ..I...... Tot�.,letrgth ..... '®.. ........, <br /> •�. Box ?' .:`l Type .filter Material �: ...Depth Filter Material ..:.�,F?r� tiJ1. <br /> Distance to nearest: Well .4.R.t E .--.., ....................T.... € <br /> Foundation . .Yf'.............. Property tine :�2...... <br /> SEEPAGE PIT <br /> Depth <br /> s?�? ,� Diameter .!z! :`...... Number . .. ...... Rm* filled Yes a No C <br /> _. _.. Water Table-Depth ......�t . ':.. ... 1.Rotk Slee ..� <br /> stance ro nealreat: Wall ..�`�i�:! Foundation ./..P. prop,- ..... .. <br /> REPAIR/ADDITION(Prov. Sanitation Permit sP f'.'I:......................................- .......:...........SDate . ......_•) . . • 1 <br /> Septic Tank (Specify Requirements i��� . . .. . . .... .. .... <br /> Disposal Field (Specify Re uirements! ,. ...._/ ............ <br /> -• !.. .. c%r a«a fi x- . ..--..f. --!.... .... ....... �6��� _.......... <br /> ._._1�.Q- --r: . ..... - ...........! ............... ................-----.......................... <br /> ..... ---•-------- --------- ------ .......... ----- ... <br /> --- .................................. <br /> (Draw existing and required addition on•'reverse side) <br /> I hereby certify that i have prepared this application and#the# the work will be don*,In accordance.with Sots jmgwle <br /> County Ordinances, State Laws, erred Rules,and Regulationof,the,San Joi4uln Local Health.Distrfct:.He+tN oswinrr er 114io <br /> sed agents signature certifies the following: <br /> I certify that in the performance of the work for.whith this permit is issaed, 1 $ham not employ any person Is such asauner <br /> as to become subject Workman's Compens ion laws of California:' <br /> -- { i <br /> Signed .. L.... .� � �- �•� -- <br /> p � j]r <br /> y --------•-- <br /> ... Jule _. <br /> lIf other than owner) <br /> FO DEPARTMENY USE ONLY ` <br /> APPLICATION ACCEPTED BY .!.... ..::. . .. 1 l <br /> :_•- ....:� :._.._..:,:::...... : .DATE <br /> Alin <br /> BUILDING PERMITASSUED ATE . <br /> ADDITIONOMME TS .. .... . ...... . .. . ........................ •------- ......................,__.........---•--....D..._.................:..........._.-..........._. <br /> �--a�� ................. �:.. <br /> '................ ........_...--.---.......................__-.........-----.........................._.............. <br /> ......................... ..... <br /> ... _._ ............................................. <br /> Firsal Ins#�ection by: ............ ............................................._._. � <br /> .._ . ----- --------•.......................__.,....---.............._.._....Dote -- ..3..- . �•---. . <br /> LSC 13 24 1-613 Rev. J' r ................ � <br /> N J AQiJIN LOCAL HEALTH DISTRICT 8/71J 3M <br /> C <br />