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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ...........0.1 1C).... 7,� <br /> Permit No. ... ................. <br /> (Complete in Triplicate) <br /> ................................................... ...... <br /> Date lssued ..;6 7s <br /> •••••••••--•-•-•----...-•................................ P'Jhii.Permit Expires,]Year From Date Issued ............... <br /> Application is hereby made to the Son Joaquin Local Health District for a permit t6 construct and install the work herein <br /> described, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ,/J ....................CENSUS TRACT ............... <br /> Owner's Name .......................................... ......................................Phone .......................... <br /> Address .... .----------_---- ................. ---------------------- ........ City ................. ........................ <br /> Contractor's Name ... <br /> wz�-—--- .....................License # Phone <br /> installation will serve. Residence A Apartment House C] Commercial :C]Tra I ler Court 0 <br /> MotelC] Other ............................................ <br /> Number of living units:.:-/,__,-7Number­of,bedrooms-,?=. Garbage.Grinder --Lo t Size ....... <br /> Water Supply: Pub]ic"System and name -------•_......-. ....._- .__ --. ._ _......... --_---------- ........ ----------Private <br /> Character of soil to a depth of 3 feet. Sand 0 Silt❑ Clay ❑ Peat C] Sandy Loom 0 Clay Loom 0 <br /> Hardpan Adobe A Fill Material ---------_ If yei,-type ........._----------- <br /> (Plot plan, showing size of lot, location of_system in relation to wells, buildings, (etc. nnuivbe pldced on reverse side.) <br /> NEW INSTALLATION.— (No septic tank or seepage pit permitted if public sewer is avbilable within 200 feet,) <br /> PACKAGE TREATMiWT SEPTIC TANK{ Size.................................................. Liquid Depth ....... .................. <br /> Capacity --------------_--- Type .................. Material-----------_t........ No. Compartments ................ <br /> Distance to nearest: Well ...................... ........Foundation .......... ........... Prop. Line ................ <br /> LEACHING LINE No. QfLines_.._____, of <br /> Len th each line.__....._:_____g L. .................... Total Length ............................0 <br /> 7 'D' Box --------__ Type Filter Material ...................Depth Filter Material ...................... ..........V <br /> • <br /> Distance to nearest. Well ................ Foundation ........................... Property Line ......................... <br /> /SEEPAGE PIT Depth ------_-------_- Diameter ................ Number .......­............... Rock Filled Yes ❑ No <br /> Water Table Depth <br /> •---•--...--••-------•-._:...:--•......I........Rock Size ................................ <br /> Distance to nearest. Well ------- - <br /> ...... . .................Foundation .................... Prop. Line .................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------_ -----------............... Date .................................. <br /> Septic Tank (Specify Requirements) ............... ---- ---.............. 1 <br /> i-•............. ......... 7............ <br /> Disposal Field (Specify Requirement ......... .. __ ® -•,• <br /> .................. <br /> 0 <br /> .......... .............. ------- ................ ........................................... ............ <br /> .................. ....................... --------------------- ...................................................................................................................­........ <br /> JDraw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health Distkct. Home owner or licen- <br /> sed agents signature certifies the following: Z <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed = -- ------ ---------- ....................­.......... Owner <br /> By .................. .. Title <br /> '0.................................. ......... .......... <br /> other thoow er) <br /> FOR DEPOTMENT USE ONLY <br /> ................. ........ <br /> APPLICATION ACCEPTED BY .................. DATE ... <br /> BUILDING PERMIT ISSUED ...................& i� ........ ....................................... DATE . <br /> . .. ........ <br /> ............. .................. ....... ............ <br /> ADDITIONAL COMMENTS ......................... <br /> ................................................................... ........................ ................................ <br /> ­ <br /> ............................................................................. ................ I. . .......... <br /> ........1-1...-..-..-.-. <br /> -.-.---------*-.-.-.-.-.-.-.-.-.I....*..........I.............................*....I................. ........................................... <br /> Final Inspection by...... . .. ........................ . . ...... <br /> ................Date, ._ .................... <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> E. H.1.3 241-'68 Rev. SM 7/79 'A-M <br />