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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete In Trlplketel ►er+nN f <br /> This Permit Expires 1 Year From Deft Issued Dote Isslud <br /> Application is hereby mode to the Son Joaquin Local Health District for a permit to construct and Install Ow wok t+rlwl <br /> described. This application Is mode In compliance with Coartty Ordinance No. 540 and exist" Rules and RpnklMer+ss <br /> JOB ADDRESS/LOCATION 2- C (0 DIS /eoe.•. CIIINM TRACT »»..•».-a....... <br /> Owner's Name Z. .f-� ...... . .....IheM ........». ........ <br /> � <br /> Address �/.3 ........ ...........Gity ... ... ................. <br /> .........._-..,....... <br /> U � <br /> Contractor's Name . ........ .license i Y . ........»......-....... <br /> t Installation will serve: Residence Apartment House❑ Commorclol C7rallw Couo 0 <br /> Motel ❑Other <br /> Number of living units: Number of bedrooms _ Y.Garboge Grinder let Silo <br /> Water Supply: Public System and nom# _ Private ak' <br /> Character of soil to a depth of 3 feet• Sand❑ Silt❑ Cloy ❑ Poor❑ Sandy Loom ❑ Ctay loam ®--�— <br /> Hardpan❑ Adobe ❑ Fill Moterlal If yet,type <br /> (Plot plan, showing site of lot. location of system M relation to wells, buildings, etc, must be placed on revem s40 0 ,4 <br /> NEW INSTALLATIONi (No septic Conk or seepage pit permitted If public sewer Is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK O Sire lkpM Depth . .........,...., <br /> Capacity Type Material No Compatlow 1. <br /> Distance to neorest, Well _. Foundation Prop. Lica ........... <br /> LEACHING LINE ( ) No. of Lines length of each Ilya Total length ........... »......... w <br /> 'D' Box Type Filter Material . ................Depth Fiber Material ...................... <br /> Distance to nearest: Well .. .. .,..._.... Foundation Property Lha . ............ <br /> _�. <br /> SEEPAGE PIT O Depth Dlomohr Numbs- Rock Filied Yet ❑ No Q <br /> Water Table Depth ..............................Rock Sire <br /> Distance to nearest, Well . .....................»...Foundation Prop. line <br /> REPAIR/ADDITION(Prov. Sanitation Permit♦ Date .... ............ .. ............. <br /> ) <br /> Septic Tank (Specify Requirements) . .... ......I...... ................ ... . .. . ... . <br /> Disposal Field (Specify Requirements) <br /> (Draw existing and requlred addition on reverse side) ) <br /> 1 hereby c*rtify that 1 have prepared this application and that the werit will be dens M accordance with Sen Jeoqulm { <br /> County Ordinances, Stet* Lows, and Rules and Regulations of the Sen Joaquin Local Hooftis District. Nerve owner M lines► , <br /> t sed agents signature ce►tifl*s the fellewing: <br /> "I certify tis,» In the performance of the work for which this permit is isswed, I atoll net employ say person In sack manna <br /> es to recetwo subject to Workman's Compento Hen laws of Oillfornle." <br /> Signed ( ./ f <br /> �. .... ........................ Owner <br /> By �J•re l �� d�S litle/�I <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY _ t <br /> APPLICATION ACCEPTED BY �� �^ DATE M 9 7y <br /> BUILDING PERMIT ISSUEDDATE .. .... <br /> ADDITIONAL COMMENTS 9'1"1;,Y 1414016, —4'0'- . .......... I.............. ......... <br /> Final Inspection by: Date 9 / / . ......... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev. 5M 7/72 3 A <br />