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FOR OFFICE USt. <br />APPILre-AfIdN FOR SANITATION PERMIT <br />(Complete in Triplicate) <br />Permit No. <br />------ ....... This Permit Epires I Year Frpm Date, Issued <br />Date Issued <br />Application is hereby mad6 to he Segos ui 04 tri for a permit to construct and install the work herein <br />described. This application is made in compliance with "Coun Ordinance No. 549 and exi ti Rules and Re lati <br />9 — au <br />&:Ip <br />S(44 <br />JOB ADDRESS/LOCATION C SUS TRACip --- <br />Owner's Name .�,doak........ -.,..Phone . ... ...... ...... <br />Address "i -17c ....... ....... city .......... .................... <br />J <br />Contractor's Name. _AD .... License <br />.1 1 ­ . ... /ZV,9..2_.5_2_0hon I --- - --------- - <br />Installation will serve: Residence Oartment House Q Commercial {Trailer Court C1 <br />SJ Motel M Other, .............. . ...........7. . ... . . . . . . . <br />......... <br />Number of living units: Number of bedrooms' Grinder L'! -.._Lot S . <br />Water Supply! Public System and name ...... ....... ....... Private <br />Character of soil to a depth of 3 feet: Sand 1] Silt C] ' Clay Peat[] Sandy Loom 0 Clay- Loom D <br />I Hardpan L-1 Adobe 44�Pl. If yes, type ....... ........ ....... <br />(Plot plan, showing size of lot, i6cation of system' in relation to wells, buildings, etc. must be placed on reverse side.) k" <br />NEW INSTALLATION: (No septic tank or seepage pit permitted if ublic sewer is available within 200 feet,) <br />PACKAGE TREATMENT SEPTIC TANK S, ............ Liquid Depth ... <br />Capacity Type Materials b�jx C.A. _ No. Compartments <br />.... .......Foundation Prop. Line - <br />Distance: ti� nearest: Well <br />LEACHING LINE NA No. of Lin;s Length of ea litre:. eTotal Lon, h .......... <br />'D' Box 11,5.. Type Filter Material 1.�V_Il.Depth Filter Material ...... <br />Distance to nearest: Well Foundation ---------- Property Line <br />SEEPAGE PIT" ept NumberRock Filled Yes <br />Water Table Depth � ................Rock Size . <br />Distance to nearest, Well /&-P ....... ___ ... Foundation Prop. Line ....... <br />REPAIR/ADDITION (Prev. Sanitciti6h-Permi� ....... __ ................... Date ..._...,.•....,._......._..__.__..j <br />Septic Tank (Specify -Requirements} u i rements) ......... . ........................... ......... __ ......-..__....._......<,....._._._................ <br />Disposal Field (Specify Riaquirements) ....... ..................................... ......... __ ......... <br />,>.....................`"..... ................................. ............. <br />. . . . . . . . . . . . .. . . .. . . .. . . . . I . . . . . . . <br />(Drqw existing and re ui4d addition on'reverse side)?',% <br />, 9 _ _ , _,.. .. � . _ <br />1, hereby certify that'l have prepared this application and that the work will " don* in accordance with Son Joaquin <br />County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local'H#alth District. Home owner or licem6 <br />sod agents signature certifies the following:' <br />"I certify that in the performance of the work for which this permit ivissued, I shell not employ any part*" ;it such manner <br />as to become subject to Workman's Compensation laws of California." <br />Signed 77. ........ <br />Byt - <br />(If other h 0 nerl <br />APPLICATION ACCEPTED BY <br />BUILDING PERMIT ISSUED. <br />ADDITIONAL COMMENTS......... <br />FOR DEPARTMENT USE ONLY <br />..................... DATE .... <br />........... --.---..........._DATE _ ... ......... .. . ____ ....... <br />............. ­­­­­­­ ............... .... ­­_ ... __ ............. <br />.......... ............. * ------ <br />............. .. ..... . ..... ....... -eLVI ................. <br />Final Inspection by: ...... .............. ... Date -*-r.��4�.�...�-,�--l.�...�,,�.. I <br />..... . ..... `­ ....... . " - ...... - ............... ............... 7*M...yi <br />E, H. 9 <br />1 -'68 Rev. 5M. <br />11�= <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />% _4 , I <br />?Y 0 , k <br />�) A ' * , <br />