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FOR OFFICE USK- <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> -------------------- ------------------------------------ (Complete in Triplicate) <br /> ---------------------------------------------- Date issued -------- <br /> T er <br /> s Pniit Expires I Year From Date issued <br /> -------------------------------- -------m...... --------- <br /> -1 . <br /> Application is herqby made to th'e Son Joaquin Local Health District for a per'mit to construct and 'install the workherein <br /> described. This op�plicbtion is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 11 ------- CENSUS TRACT ----=5-------V...... <br /> �YD 5 ------------- <br /> JOB ADDRESS/LOCaM_ION _16- -------------I-------- -- ----- <br /> 4 <br /> Owners 'Name _E� DA.RTBOF-F ----------I-------------------Phone ------------------------------------ <br /> M.- I - ----- ----- <br /> ' -I:___ - l--------�5 <br /> ? 0, 13 0 y ---M-Tr—p---------------------------------------•------- --------- <br /> Addressy 01IN ---- P(AiX------7�--------- ---------- <br /> , --- <br /> -------License ------ <br /> ------ Phone ------------------------------ <br /> ------- <br /> Contractorr ------------------------------------------------ <br /> rcial []Trailer-Getiot a� <br /> installation-w-illserver Residence 0 Apartment House,F1 Comme <br /> Motel E]Other ---- ------------------------ -------------- <br /> .... ---------- <br /> Number of living;units'_*j rooms __--__-_____Garbage� Grinder -NO---- Lot Size <br /> .,,,----Number of bed <br /> I T j-�_� a- f -------------------- Private <br /> ---------------------------------------- <br /> ly:,VublicS, 'f <br /> Water ysim'cincl name --------------------------------------- <br /> 4P I <br /> Clay Peat❑ Sandy Loom Tr/Clay-Loam ❑ <br /> Character of soil to a depth,of 3 feet, Sand'El Silt 0 <br /> 'ti r <br /> Fill Material ------------------- ai <br /> ------ <br /> V -_ <br /> 1_:�It Hardpan E] Adobe Ej If yes,type.e <br /> (Plot plan, showing size of 16t,ilocati'o'n'of system-\in\rel8ition to wells, buildings, etc. must-be PlEc6d' ot?'reyerse side.)% �Ik I <br /> (No septic tank or seepa t #ed if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: <br /> depth ----/---�rn-------- ------ <br /> PACKAGE TREATMENT j ] SEPTIC TANK:[�� Size__ Q, -------------- Liquid D <br /> Compartments _---2-----•_----ypePRE_F05__ Material'--CqN CRT-_ No. <br /> Capacity _/7PQ------ T I r 4- . Line 's......4----------- <br /> Distance to nearest: Well .......7t7------------F6undation ------- Prop --- ---e <br /> -(------------- Total Length -------------- <br /> LEACHING LINE �No. of Lines ----!��---------- Length of each line----7V <br /> 1 15 'D' Box Type Filter Material Depth Filter. 'Material ---_/q•---------- <br /> Y_ R — 7V -+--.. Proper <br /> tr <br /> ell 0-------------- Foundation 0.......... .. ty Line -- -------- <br /> r11 Distance to nearest: W <br /> Di'mefer ---------------- Number -------- ------------ Rock Filled yes No <br /> SEEPAGCPIT Depth 3--------- --------- a ------ <br /> Rock-8ize--- ------------------ <br /> Water Table Depth ---------------------- ------------------- <br /> ----------------- Prop. Line ---------------------- <br /> zD`stance.to nearest: Well ----------------------------------------Foundation <br /> Date ------------- --------------- <br /> REPAIR/ADDITION(Prev..'�aniitafion Permit -------------------------------------------- <br /> Septic Tdnk (Specify Requirements) ---------------------------------------------- ---------------------------------------------- <br /> Requirements) -------- <br /> ------------------- <br /> ----------------------------------------------------------------------------------------------------------------------- <br /> Disposal �Field (Specify ' <br /> --------- <br /> i -------------- ----------------------------------------------------------------------------------------------I---- <br /> ------ <br /> ----- <br /> ----------------------------------------------------------- <br /> --------------------- -------------------J------ ----------------------------------------------------------------------------------------- <br /> ---------------------- <br /> j <br /> -------------------7-----------------------------------;--- required-.addition.I (Draw existing and required-ad on-reverse side) h San Joaquin <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in a with accordance <br /> of theSan Joaquin Local Health District. Home owner or liven- <br /> sed agents signature certifies the following: <br /> I certify that in theperformance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become':subjed to Wortkn'Vj!,�o ns ti n laws of California." <br /> - --- Owner <br /> - ---------------------- <br /> Signed <br /> ----------- ---------------- <br /> By -----------------I',(If <br /> ----------------------------------- --------------------------------------------------- Title -------- ---------- ---- ------------------ <br /> ',(If other than owner) -j <br /> FOR DEPARTMENT USE ONLYII <br /> APPLICATION',ACCEPTED BY ------------------------------ DATE ----------- <br /> ­­ --—-----------DATE-- ----------- <br /> B DING-PEWIT15SUED----—------___­_ ------------ <br /> UIL -------------------------- <br /> ADDITIONAL COMMENTS -------------------------------------\-*'-,'c----------- ------ <br /> ------------------- <br /> --------------------------------------m- <br /> ------------------------------------------------------------------------------------------------------------ <br /> ------------------- ------ <br /> ----------------------------------------------- 2 - <br /> ----------------------------- ----------------------------------- ....-- ------Date -- -- ---- X11,--- <br /> Final Inspection --------------------........................ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 5 W 9 1-'68 Rev. 5M <br />