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FOR OFFICE I.fSE:- �APPLICATION FOR SANITATION PERMIT9_ 4 <br /> f <br /> --------------- - ----------------- <br /> Permit N <br /> (Complete in Triplicate) <br /> ------------------------------------------------------___ This Permit Expires 1 Year From Date Issued <br /> Date Issued __ - . <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with Coun .,Ordinance No. 549 and existing Rules and Regulations: <br /> ! �- <br /> JOB ADDRESS/LOCATION �ZZ __- __-VV©-QDWA� ------ �EnfTA_L-- -----------CENSUS TRACT _ _� �-•------- <br /> Owner's Name --------Ei>-------FuRraao---- -------1- -------------- .- -------Phone---------------------------- .._.... <br /> Address -----------672-q?---- 5 A---- AB.ODL_g/_ARD---i <br /> --- <br /> ---------------- City ---MA_& TF4--"---- -------------------------------- <br /> Contractor's Name _` XD8N---------------------------------------I ------ ------.License # ------------------------ Phone ---------------•---- .-------- <br /> Installation will serve: Residence eApartment Housef] Commercial:❑Trailer Court i❑ <br /> Motel ❑Other_ _T-Y_ <br /> -------------------------------------------- A� <br /> Number of living units:_ <br /> ._I_____ Number of bedrooms --2----Garbage Grinder WO--- Lot Size 5— �a0 �______________ <br /> �----- --------- <br /> Water Supply: Public Systeman. l.:{namel----------------------------------------------------------- Private <br /> Character of soil to a depth of 3 eet' Sand'❑ Silt C] Clay ❑ Peat Sandy Loam Clay Loam <br /> r.- <br /> _.__�_ <br /> _- - . _... .. _ _ Hcfrdpp' D—A�obe: •.`�i11.1 Laterigl ..: L Yes.?YP? <br /> - . ------ - <br /> -� _ _ _ , _ <br /> (Plot plan, showing size of lot, Iolcation of: system king m3cgi,994to wells, buildings, etc. must be placed on reverse side.] <br /> NEW INSTALLATION: (No septic.'tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC-TANK;[ I Size______ q p <br /> `-----•--------------------- Liquid Depth -------------------------- V <br /> Capacityi-_J-------------- -- Type -------------------- Material.--------------------- No. Compartments ---------------------- <br /> . I <br /> to nearest:Well--_ __�---� _ I_____Foundation .___________________ Prop. Line ___________________ <br /> - <br /> LEACHING LINE [ ] No. of f Lines -------------------�. Length of each line---------------------------- Total Length -------------- -------- <br /> D",Box ________ Type Filter Material ____________________Depth Filter Material ------------------------�_._...-- <br /> - <br /> Distance to nearest: Well ________________________ Foundation Property Line _________________-_____ <br /> SEEPAGE PIT [ ] Depth ---- --------------- Diameter --------._--_--- Number -----_---------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth __`-:_ - ---------- - <br /> = __---Y----�----w -� Rock Size _________________ <br /> --------- <br /> t , <br /> Distance to nearest: Well n,_-------- __------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- --------zZ �_`--_______________ Date ________-__________.__.._.._.____ } <br /> Septic Tank {Specify Requirements] ---------------------------------- . <br /> Disposal Field (Specify Requirements) U} ._`�.�, Jif T4_60 ---/--!_N `-------- �0-------------------- <br /> --------- ' G!/V�------------------------'N- �---------------- -------------------------- --------- ------•----------------- <br /> - -------6- --� i>��-----XuArgm------- -------------------- <br /> (Draw existing-and required addition.on revea�s� sid ]. <br /> I hereby certify that I have prepared this application and that the work will beoii in accordance with San Joaquin"` ! <br /> _County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Loc I'liealth District. Home owner or licen- <br /> sed agents signature certifies the following: } <br /> "I certify at n theperfor ce the work or'which this permit is issued, I shall not employ any person in such manner <br /> as to b subject to W ma `s Compen ion laws of California." <br /> Signed -- ------- - --- ----- - <br /> - ------ - ---------------------------------------•- <br /> Owner <br /> B -- -- ----- -- - ---------------------�t6�'--------- Title ----------- ----------------- -------------------- <br /> (if other than owner) <br /> ----�� FOR -DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY I 1 = ------------------------------ -------------- -----------` DATE ------- -------- <br /> BUILDING;PER::NI'iTY155UED `w-- Y _ - SATE - ----------------- <br /> -------------------- <br /> ------ <br /> ADDITIONAL -WMENTS _ - 5:x[ 'r 1 '�'� '• � = <br /> ------------ ----------- - - ---- - <br /> ------ -- �: E_ si=p_ <br /> ----- - ----- ------------------------ -- -- ------- --=- <br /> ------------- <br /> '�• ]tel__-.__ ----- . <br /> FinalInspec ' by: -- - - - - -- - ------ ------ -- --- - - ----- ----------------------------------------- <br /> ---Date ----- - °� --- �-- - -------------- <br /> SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />