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`r F69 OFFICE USE: <br />APPLICATION FOR SANITATION PERMIT <br />::..::...................._..._.,......... lCompleta In Triplicate) Permit No. 7.�'�1... <br />.......................... �, <br />` This Pormlt Vxpiros 1 Year From Dots Issued Date �aaued �...! <br />Application is hereby made to the San 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. 544 and existing Rules and Rogulations: <br />JOB ADDRESS/LOCI. ............. c1. . ............... <br />.... � .tr.�-Qc'o�� R <br />Owner's Name...!� .�.. .. .. 1� ... <br />Address .. (fid-� dp�r / �f..�,..... City a!�✓p.• ................. �" ............................ <br />Contractor's Name .. !.. ... ^:-•tet:. :......License # f.A.A.3.'.�.Y. Phone :............................ <br />instollotion will serve: Residence @KApartment House Q Commercial oTraller Court 0 <br />Motel J] Other ' <br />Number of living units -1 ...... Number of bedrooms ... ......Garbage Grinder ............ Lot Size .r-�aX.............. <br />Water Supply': Public System and name........................................................ ...................-.................................Private <br />Character of soil too depth of 3 feet: Sand E J Silt O Clay[] Peat[] Sandy Loam #Clay Loam Q <br />. Hardpan O Adobe 0 Fill Material ............ If yes, type .......................... <br />JPlot plan, showing size of lot, location of system in relation to welts, buildings, etc. must be placed on reverse side,,C <br />i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br />PACKAGE TREATMENT (] SEPTIC TANK ] Size ................................................ Liquid Depth ........................... <br />Capacity YP . Material ...................... No. Compartments <br />Distance to nearest: Well ...Foundation ...................... Prop. Line ............ I....... X <br />LEACHING LINE [ ] No. of Lines ........................ Length of each line............................ Total Length .......................... <br />'D' Box :..'....'..... Type filter Material ....................Depth Filter Material............:.....................1........' <br />Distance to nearest: Well ........................ Foundation ........................ Property Line ......................+ , <br />SEEPAGE PIT Depth ....... Diameter ............4. <br />.. Number : .... Rock Filled Yes [] No <br />Water Table Depth ................................................Rock Size ................................ <br />Distance to nearest: Well •` ..........Foundation .................... Prop. -Line ..................... <br />Ri:PA1R/ADDITION (Prey. Sanitation Permit 9 .--.......•...............• Date J <br />Septic Tank 15pecify Requirements) .........._...........................................(`. _ .... ....... <br />Disposal Field (Specify Requirements) .4�l�t.�.� _/_1�/. aGr-.-.......i... .d.ti... .. ............. 1 <br />... . <br />.......... _........................... .................. (Draw existing and required -addition an reverse side) <br />I hereby certify that I have prepared this application and that the work will be done In accordance., with San Joaquln" <br />County Ordinances, State laws, and Rulas and Regulations of the San Joaquin Local Health., District, Hme 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 sholl..not. employ any porton in such manner <br />as to become subject to orkman's Compensation laws of California.'• <br />Signed ...................�lr* ._.........._..... Owner <br />._GlBY ............................1.F. ..d`t.....................(if otowner) r �� <br />APPLICATION ACCEPTED BY ...? .. <br />BUILDING PERMIT ISSUED ........................ <br />FOR DCPARTMENT USE ONLY i <br />DATE ..�.^. .`. r1.6... ... ...: <br />....................................................................... DATE ........................... <br />............... <br />ADDITIONAL COMMENTS .........................................................._....... <br />................................................................................................................................................................................................ <br />......................................................................................................................................... <br />.:....................... .......:- .. .. .............. <br />'....... <br />Final Inspection by:.........C... .....Date.7­!../:..2 �.. I .............. <br />............................................. <br />LH 13 24 . 1-68 Rev, 5M 5AN"JOAQUIN LOCAL HEALTH DISTRICT -:! 8/7h 3M <br />