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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------ ---------------------------------------- ---------- (Complete in Triplicate) <br /> -------------- --------------- Date Issued ---- <br /> This Permit Expires-1 Year From Date Issued <br /> a permit to construct and install fibs'work herein <br /> -------------- <br /> ' - <br /> Application is hereby made to the San Joaquin Local Health District fc;r <br /> described. This application is made in compliance with County ordinance Nc�._5,49 and existing Rules and ReqV97 <br /> ,10 <br /> ---I - CENSUSTRA ---- .�._ <br /> t <br /> Phbne ----------------- ------------------ <br /> 16 ------ _11�------------------ <br /> J <br /> Owner's N IONZ� ---- <br /> OB ADDRESS/1-0-ATION,�"i- <br /> ame S�!--- ------1 <br /> - ---------- -------------- City N're---re,------------------------------------------------------------- <br /> Address se #XU3 Phone ---------------`-=•---------- <br /> Contractor's Name ---------ex­­Zd_�---- ---- -t' r -—---------------- --------- <br /> Residence ❑Apartme H use-E] Commercial :oTrailet Court 0 <br /> Ihstallation will serve: 11 • <br /> -!! -------- .. - 41--.71L& <br /> Motel [] It <br /> -------------- <br /> Number of living units::_--------- Number of,bedrooms -------------Garbage Grinder ------------ Lot Size ----------------------------- <br /> Private 0 <br /> Water Supply. Public System and name ---------------------- ----------------r----------------------- ---------- ------------------------------------ <br /> t <br /> Character of soil to a depth of 3 feet: Sand'E�3/I C) Clay 0 Peat E] Sandy Loam -0 Clay,L!oam El <br /> •-rJ FillMateri0l­ ------- <br /> Hardpan Adobe ------ <br /> *d <br /> c. must be placed on reverse side.] <br /> (Plot plan, showing size of lot.. location of system in -relation to wells, buildings, et available within 200 feet,) <br /> '(No septic tank or seepage pit permitted if public sewer is Ova A <br /> NEW INSTALLATION: <br /> PACKAGE TREATMENT J[ ] SEPTIC TANK;[e Liquid Depth �-- ------------------- <br /> Compartmen.t ----------I------ <br /> f - ' ---------- NO, s <br /> .CapacitWA�1____1(_ Type <br /> 'Distance' to nearest. Well .........JA4----------------------Foundation ----- PropYLine <br /> ------------ <br /> e----_144_11----------- Total Length <br /> LEACHING LINE Length of each [in <br /> al ---- ......Depth Filter:Material ---6------------------- -------- <br /> t'D�"iilox Filter'Materi <br /> Property Line. <br /> -------- <br /> Distance to nearest: Well <br /> Diame'ter ---- ------- Number ------------ -------L------- Rock Filled Yes 00 <br /> SEEPAGE PIT IDepth --------- <br /> 9 J j�� ------------------------ <br /> __!_Water-4ablezbeptli-—------------- -_ ----------------- --------R0.ck Size <br /> -Foundation /C Line ----------- <br /> hCe to nearest: Well --------�4`------------------------- --- ----------- ---- Prop. <br /> -Dista <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------=-------------- -- <br /> ------------------------------ --------------------------- <br /> Septic Tank (Specify Requirements) ---------- ---------------------------------------------------------- <br /> II A I ---------------- ----------------------------------- <br /> Disposal Field (Specify Requi�'ements) ----------- --------------------------------- ---------- =---------------------- <br /> -------------------------------------------------------- <br /> --------------------------- ---- <br /> ---------------------------------------------------- -------------------------------------------- V <br /> -I <br /> ----------------------- t--------------------------- -------------------------- ------------------------------------------------------------------- <br /> --------------------------------------- - (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> 'the-San-Joaquin-Local -Health District. Home owner or licen- <br /> sed agents signature certifies the following: <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 <br /> as to become subject to Workman's Compensation laws of California." <br /> Owner <br /> Signed --- <br /> Title <br /> -----I----------- <br /> --------------------------------- <br /> By --- <br /> (If other than owner) <br /> FOR DEPARTMENT flSE ONLY <br /> DATE., ----------------- <br /> APPLICATION ACCEPTED BY <br /> - - -------------- ---------------------------------------- <br /> BUILDING PERMIT ISSUED :.�60�------- �l------ �f - DATE ------------------------------------------- <br /> �MME -------- <br /> ADDITIONAL TS -7 <br /> -- --------------------------------------------------------------------------- ----------------------------- <br /> ............ <br /> --------------- --------------------------------------------------------------------------------- . <br /> ---------- -------------- ---------------------­ 5Z��,3 -- ---- <br /> /- -------Date --------- ------ <br /> -------------- -_ .---- - <br /> Final Inspection ----------------- -------------------------------------- ----- ------------ ----- <br /> _e --------------- <br /> ---W-e, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />