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FOR OFFICE LISE- APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> ----------------------- .-•---••---•-•-- (Complete in Triplicate) <br /> ------------------=---•----------------- I Permit ExDate Issued'4�.6-:4A <br /> This . <br /> s Expires 1 Year From Onto Issued <br /> --------------------_- ................... <br /> Apr)lication-it-hi§ab-y-etib'd'-to-th*eF,Sdn ,Joaquih,-L&di--He:alth-District for-a--permit-io­construct and- install-the work herein 1 <br /> described.This application is mdde\in(,complionce'w.ith,Cdu6tyOrdinance No. 549 and existing Rules and Regulations: <br /> -----..CENSUS-TRACT ._rt_6......... <br /> OV" .... .... <br /> J ADC4ZESS/LCFCATI'0W_0..7__ 46 <br /> �-Aw-A <br /> Owne'r's Name .-IAlf-'s------.4w. --------__...._- •---•-...._ ..............Phone.... <br /> ............... ............... <br /> J01 7- --------- - ----------------- -----------city bw <br /> Address ----cc A�w ol VcW/ — <br /> -------------_-----_-License ----------- Phone <br /> Contractor's Name . _;V--apil-'e- <br /> -artment-HouseiO_Cornmercial-[]Trailer Court 0 <br /> Installation wilrsirve. <br /> ,f Motel E]Other <br /> Number of living units:........... Number of bedrooms .....Garbage. Grinder - --------- Lot ......... <br /> 6 ..._.._..Private <br /> Water Supply- Public System and name .....................I,_-- -------------- ...... .................. .......................... <br /> L,Cldy Loam_.El - <br /> Silt 0 Clay 0 - Peat[] S ndy Loom'9--60 <br /> Character of soil to a depth of 3 feet: Sand'E] <br /> Fill M6terial 'No. if s,type .......------ - ------ <br /> Hardpan Adobe E] I <br /> (Plot plan, showing size of lot, location of system in relati to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit.perm! ecl if pu lic sewer is available w thin 200 feet,) <br /> ... �_ I Depth PACKAGE TREATMENT SEPTIC TANK:[ ] S .......... L qui I d Dep .............. CL <br /> Capacity Type P.A,.qg W1, -.OA044' ampart ments 2!n............. <br /> Material.(? - <br /> a. <br /> Distance to nearest.- .............Foundation ... -Of Prop. Line ..-- ...... <br /> T <br /> Beach line-........................... To I fteiigth 13010........... <br /> hgt <br /> LEACHINGLINENo. of Lines <br /> V Box ------------ Type Filter Material Depth Filter Materia ... ............................••.._... <br /> Distance to nearest: Well Foundation .. ......... rc��ertj Line ...................... <br /> er -------_------t............... Yes 0 No <br /> . ......... Numb R k**Fiired <br /> SEEPAGE PIT Depth -----------------_- Diameter ...... <br /> Water Table Depth <br /> ...........Rock Size ---- <br /> ....--------- --------- ---........ <br /> Distance to nearest: Well ----------­- ...............Foundation--------------- --------jPr6p. Line --_---_--...... <br /> Permit# ........ -------­-­ ------... .... <br /> REPAIR/ADDITION(Prev. Sanitation ........ Date _.......... <br /> -------------L .... .. ----------- ---------................. <br /> Septic Tank (Specify Requirements) -------------- ....... -------- <br /> Disposal Field (Specify Requirements) ......6*r--I?-TI4"±,---%.N.YjN-,.,---.,.Ujl-r+.f----....I-Z.c <br /> W_ <br /> .. ...... . .... ........W.Jkg;��...Pax..... <br /> _4EA-C-14-------1,1 .......................... --- ----------- --------------- -z---- <br /> *, - <br /> � ,S.w exi_st'i_ng'a_nWreq required addition on reverse side). <br /> I hereby certify that I have-piipared this application and that the work will be daheiln/accoidance with Son Joaquin <br /> County Ordinance;, State Laws, and Rules and Regulations of the Son Joaquin Local Healih-Mistrict. Home owner or licen- <br /> sod agents sigift'Ituere certifies the following: <br /> I certify that In the performance of the work for which this permit Is issued, I *hall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California."! <br /> ---------------- <br /> Signed .. ........ ... . ---------------..-... .... Owner--7- ------------------------------------------------- ........... <br /> .................... Title'By .... .. <br /> (If other than owner) <br /> Fbit-DEPAitirMENT USE ONLY <br /> 0 - <br /> APPLICATION ACCEPTED BY ........ ........................ ...................................... DATE .......?:7 ........7........ <br /> BUILDING PERMIT ISSUED ......... <br /> ---..I _ --- . ...... .. <br /> ------1. �..... ......... .....................-..-..-..-­.-.-.-D.-.-A....T..E........................................._...........................................-..-...-..-. <br /> .-.--..--.-..-.--.-- <br /> ....-.-.... ---------------- ------ ------- ------ ----- <br /> -R < - - --------.---- ----------- - <br /> ADDITIONAL COMMENTS -------- -----------_-------- .......... . -••-•--•--•--•----•....•-••••••----•••--•.._................... . ...... <br /> ...........—........................... <br /> -------- - ------ -r ......------ <br /> - . .- . - - _ __.............. ---_-------- ..................... 2Final Inspect! ....................Date ..._ -- - -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />