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FOR OFFICE USE: r <br /> APPLICATION ICOR SANITATION PERMIT <br /> (Complete In Triplicatol <br /> Permit No. ., <br /> :6.Z, <br />.. M . . .............. This Permit Expires 1 Year front^DaM Issued. M.•. Dateissued 2.:1 .. <br /> Applicatlon 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 County Ordinance No. 549 and existing Rules and Regulationse <br /> 30B ADDRESS/LOCATION ..Z��:. .. ... .. .... I ........:.......CENSUS TRACT ... ......... ... <br /> Owner's Name .._ '. ..... a!1.. . . ......................} .Phone .. V:� : .z:]...... <br /> Address .... ..........- ... , �.. ,city �y `' ....... <br /> Contractor's Name .......:..........: . .. ..-V... . ....... ... .........License#,�-'F.�F.,.:.�.`f .. Phone . .............r` 7... . <br /> Installation will.serve: " Residence Apartment Houso0 Commercial OTraiiet Court <br /> Motel[)other...... .... ... ? -- i <br /> Number of :living units:...:�..:. Number of bedrooms ....��.... Garbage Grinder � W.Size ............. <br /> Water Supply: Public System and name ... . <br /> .._..... : ... .' � ..... ........:................. <br /> .......:......Pri+rate <br /> Character of soil to a depth of 3 feat: Sand i3 Silt 0: Gay 13- Peat Q So*Leans C3 . Clay Imam 0 <br /> Hardpan[) Adobe f� Pill hkoterial .......... .if yam.MPst....... ......... <br /> E <br /> IPlot plan, showing size of lot, location..ofYsyslernln relation to wells buildings, et& nwst be pla ed an reverse side.) <br /> NEW INSTALLATIONS INo septic tank or seepage pit permitted if public sewer is avalloWe within 200 feet,)' <br /> PACKAGE TREATMENT .E SEPTIC TANK; ) Sizer: . . i .: .....:- Uquid DiPth ..................... <br /> Capacity ... i Type ............ . mciftrial.' i No. Cotnparhtts ma ................ <br /> ' <br /> Distance, to nearest Wall -... .....�r __ :..Fotendcltiori.: .-::I Ir+op. Lute................»....:°� <br /> LEACHING LINE [ ) No. of Lirtei '. `�: � 'ef,aarh{.life. '" ' # ... ToaI,Length ......................( : <br /> 't1' tax ....... Typo Filter Maf ial t ................ flepth,�Fgtdr Material ...... ............................ <br /> Distance to nearest;iWell._...:__..__ .. .... Found Bari`. .. l ........... iProperfy i.iree. .....:................. <br /> SEEPAGE PIT I I Depth ........ ...... .. Diameter ........... Number ........._.f i..::....... Rade filled Yes Q No C) <br /> Water Table Depth ...............................................Rodi Sire . . ..: l <br /> Distance to nearest: Well ........................................Foundations . ................ <br /> Prop Line .........».... .. o <br /> a <br /> REPAIR/ADDITION IPrev: Sanitation Permit ........ . Date ____) _ <br /> I <br /> Septic Tank (Specify Reg.ui►em_ntsj .................. _ . ............................. ..... ......... _ <br /> Disposal Field ISpecify Requirements) . _.C�..4. .J ....V ....... �...-r. .... .. .... .. »................................... <br /> � 1 <br /> ............................... l --...- l -�•.....r��.. .... O�S'; .L. _..._.... ......................... l .............:. . .. <br /> ..... <br /> •-- --••-•..........................--------- •------•- ----•-.--••-•-•---............ .....:.....__:...................... - ........:...... . .:. ....-•---......................... . <br /> q -- 7 <br /> (©raw`exxis-ttingand required addition on.reverse side) <br /> I hereby certify that i have prepared:this application and that the work will be done. In accordant with Ilan 4oaquin <br /> County Ordinances, State Laws, and:":Rules and Regulations of tete San Joaquin Local HaMls Dlstr!ct. Howe owner or. 111144th <br /> sed agents signature certifies the following: t <br /> "I certify that in the performance of the work for which this permit is issued, I shall net ot"ey any owsm In suds <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .._.---- .... .._ - •--• Owner . <br /> ,�' A � --•...................... <br /> ...... <br /> By _......../ i.-�/--� ------------------------- Jitle <br /> ........................... -- -- '. <br /> (If than owner) <br /> R EPARTMENT :USE, ONLY <br /> APPLICATION ACCEPTED BY -_.. .. .... .... ............... <br /> : :. .DATE,........; -.,.._... 7� = 4 <br /> BUILDING PERMIT ISSUED .... ,__,.. DATE ............................ <br /> ADDITIONAL COMMENTS .... / .OIG ..----- .............:........._............ <br /> ..........----------------------------- -.._._ ..__........ ----•- .._.._... ....-- .. ._.._,_..............• . . <br /> . ... ........... . ..........- <br /> . -• <br /> .......-- •----------------•---......--•------..........._............--.•-•---._....._..... ..._........__......._ . .... <br /> .._......-•......:................. ...... . . <br /> FinalInspection by .................................................. .............................Date -- ..........•-•-•- <br /> E'Il 13 2h 1-68 Rev. <br /> SAN :lOAQUIN LOCAL HEALTH DISTRICT $/71; 3M <br />