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FOR OFFICE USE: <br />.......... <br />............... .......... <br />C". �, �, e, 0 1 <br />APPLICATION FOR SANITATION PERMIT <br />(Complete in Triplicate) <br />FOR Of F1 <br />LL Ub& <br />Permit Nor.... ........... <br />gate I A /— '? .2 - <br />....... __ ......... This Permit Expires I Year From Date Issued <br />Apphcotion is hereby made to.the San Joaquin Local Health District for ' a perAit to construct and , install the work herein described. <br />This application is made in compliance with County Ordinance Nlo4'S49 o'n8'existing Rules and Regulations; <br />-y- - �_.CENSUS TRACT ............ 7 <br />JOB ADDRESS/ LOCAT !ON 1 o4 <br />Owner's Nome Phone <br />t ...... <br />el. 7 60 -v _.City, <br />,.2 Zip ... .....Address_ ... 672 <br />8 Y <br />Contractor's Name._ Lic ense <br />instollat;on will serve; -Residence Apartmeht,HouseZi Commercial Trailer Court i <br />Motel jr-1 Other,�.. . ............ <br />Number of living units:...., of bedroorns,....3--Garbage Grind"_/V6..Lot Size.... <br />Water Supply; Public System and name... ..... ... ... .... ......_.....Private <br />Character of soil to a depth of 3 feet! Sand CJ- Silt 0 Clay F-1' Peat L'I Sandy Loom Clay Loom 0 <br />Hordpon-j�]',=Adobe U-- Fill Material <br />23 - <br />(Plat plan, showing size of lot, location of system in relation to wells�buildinqs, etc. must be placed on reverse side.) <br />NEW INSIAII.ATIOM (No,septi , 6,tank or seepage pit permitted. -if public sewer is available within 200 feet,) <br />ir <br />PACKAGE TREATMENT I I SEPTIC .... ...... _.....Liquid Depth <br />10 <br />...... . ... <br />f Copccit,y;,%P2-43O..Type_P.A0e.C4`Af. Material, Compartment 110 <br />Distance to nearest: Well... ..'__Foundation. Prop. Line..... <br />LEACHING LINE No, of Lines --I - —en. .......... Lle'nqih of each line.. ........ .. Total Length <br />44 <br />'D' Box Type Filter-Mateii6l Depth Filter Mater......... <br />Distance, to nearest: Well --- Founclation......,;ZY .. Property Line., <br />SEEPAGE'PIT Depth :2 Rock Filled Yes No L� <br />Water Table Depth.__ ....... <br />.....Rock Size_ <br />DistancwtoAeorest: Well__ e0o_ . <br />................. _Foundofion,__&_V_ _..Prop, Line.10 <br />REPAIR;,ADD'ITION (Prev, Sanitation Permit ............ ......... ....... <br />Septic Tank 'Specify Requirementsi .... ........ <br />............................ ............. ......... ....... ...... <br />Dispos�l �ield {Specify Requirements)- ... 4— ............ ............... <br />............. ........... ............ ....,r,..,............. ....... ...... ........ <br />.... . . ... . ........... ...... <br />lbrave existing and —required ;ddffilWn ren ie- 41rsi <br />I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin u <br />Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed e"I <br />signature certifies the f6ilowing: <br />"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br />to become subject to Workman's Compensation laws of California." <br />Signed ...... 0 <br />' Owner <br />. <br />Title <br />(if other than owner) <br />MENTXJS9 ONLY <br />....... ___DATE <br />APPLICATION ACCEPTED BY ...... <br />......... BATE -__ ......... <br />DIVISION OF LAND NUMBER ...... ...... ........... <br />Ar�'01TIONAL COMMENTS ..... ......... ......... ......... ....... ... ............... <br />T, - - � , .., 'I, )t/ ............. <br />.. 1 11 .... . ...... <br />Final Inspection by. <br />EH 13 24 4 <br />................ ......... .................. -1-1--- ........ <br />.......... ..................... ......... I ................... ......... ­­._ ...... ... .... <br />....... .... ­­­ ... ............ ___­ ....... ............... <br />........... ....... <br />LOCAL HEALTH ]DISTRICT fes 2i6n MV, 7J76 3M <br />