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jR OFFICE USE. APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> ................................. ACompleteln Triplicaft) <br /> ........... <br /> ........ ........I........ Date issued jg� ..... <br /> This permit Expires I Year From 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 County Ordinon IVa. 549 and existing Rules and Regulotions- <br /> ..CENSUS TRACT ........................... <br /> JOB ADDRESS/LOCA N . ..... .................... <br /> Owner's Name ............................................•---......._,...._1...... ......Phone .... ......... ......... ----------- <br /> Ity <br /> /:.Lj .............. <br /> ..............Ci ..... .. <br /> . ............... <br /> .... ...... <br /> Address .... <br /> __License# Phone <br /> Contractor's Name -------- ............................... .... <br /> Installation will serve: Residence[I Apartment House 0 Commercial.oTralliK Court 0 <br /> Motel [3 Other ...... <br /> .Garbage Grinder ............ Lot Size .. . .... ........ ......... .......... <br /> Number of living units-_... ----- Number of bedrooms ... ....... <br /> Water Supply: Public System and name ..___.__.-•-...........;................................................. ... ..............................PrI'vuteW <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 <br /> Clay (:] peat 0 Sandy Locim•-0 Clay Loom <br /> Y <br /> Hardpan[] Adobe Fill Akaterio If Yes,type...4..................... <br /> (Plot plan, showing size of lot, location of system In relation to 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 /> Liquid <br /> PACKAGE TREATMENT SEPTIC TANK Sir..... Depth I..e.......... <br /> Compartments .......a�........... <br /> Capacity Type P'Le.., Material.._. P-rop.jine <br /> tance.to nearest- Well ............ ......Fqupdation-, <br /> eng . ................. <br /> .......... Total L th� ...OF <br /> LEACHING LINE fie'-to. of Lines ........ ......I......... Length of each line I/ <br /> V Box 4D..... Type Filter Material Depth Filter Material .....ZA­.......... <br /> Distance to nearest, Well ..-_./?.___-••-•._... Foundation ... .......... <br /> ....... Property LI, <br /> Diameter 33..- Nuim' ber ......... .............. --- Rock Filled Yes 0 <br /> SEEPAGE PIT Depth ....... 0 <br /> Water Table Depth .......�k'Jfl........... ..........­_r--Rock Size .. . .. .. .. ............. <br /> ------ --_...Foundation Distance to nearest: We ..... Prop. Line jcrl---------- <br /> .................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date --------- <br /> •..... ...................... ....................- <br /> Septic Tank (Specify Requirements)-_--_ ------ ------ ---- -- 7......a.......­­­............. <br /> Disposal Field (Specify Requirements) ---- .............. ............ ...............I..........17............ ..._•-•-......•.___....._ <br /> . . <br /> .......... ...............m�................. .............. ........................ ...... ..................... <br /> ------------- .............. ......... <br /> ............. --------------------------------- ............................ <br /> -------- ------- <br /> ------I---­-------_----- --------------- -------------- Draw-existing-and--required addition on reverse side) <br /> I hereby certify that 1-have prepared this application andthat the.,'work...will.be doneAn accordance with Son Joaquin <br /> County Ordinances, State Lows' and Rules and Regulations of the Son Joaquin Local Heal&Dlstrid. Home owner of 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 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California!' <br /> Owner <br /> Signed ------------------ ----------- ----- .......... <br /> ............ <br /> ---------vt---- -------- -- -------- <br /> By ----------_------------- ----------_------- - ...................... Yi4le <br /> (if than owner) I <br /> FOR DEPARTMENT USE; ONLY <br /> APPLICATION ACCEPTED BY _. -`---•--------••----------- ............. .....................DATE <br /> BUILDINGPERMIT ISSUED -------------------------------------- -----------­­........... .............................DATE <br /> ADDITIONALCOMMENTS ------------- ------------_---- ............................... ----------- --------_------_---- ----- ....................... <br /> --------------­---- ...... <br /> ---------- ....... ... ........I......m----------------­---:------------------------------------ -------- <br /> ---------- , -%. . ------- --------------- A---------------­-- ........ ........... .................... ...... <br /> ---------------- .............. ............... ...........­.............. <br /> . .. ............. <br /> - -------------- ------ ....... ..... <br /> .............7------- ------ ----------------- <br /> . .... Date ........... <br /> Final Inspection by: <br /> EH 13 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />