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n <br />I <br />FOR OFFICE USE: <br />- --------------- ----------------------- <br />-------------------------------------- I -------------- <br />--------------- --------- --------- --------------------- <br />APPLICATION FOR SANITATION PERMIT <br />11 # <br />(Complete in Trilpliate) <br />This Permit Expires 1 Year From Date Issued <br />Permit No. <br />Date Issued �790::_7.0_ <br />Application is hereby made to the Son Joaquin Local Health District for a per ' mit to 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 ------- - -- -- ------------- ------ ------- --- ----- ------- k ----CENSUS TRACT -------------- ----------- <br />---------------------- Phone V66 S, <br />Cts <br />Address --------------------------- ef ------- ----- - - ---- - ---------- --- ----------------- <br />Owner's Name ---------------- --- ------ --- -- ------- <br />/ 16Z,.J" - �__ , .-,t 16, <br />Contractor's Name --------------- --------- - ---- - - ---------- ---------- Uice-fisel# ------ Phone <br />Installation will serv6-. Residence 0 Apartment House -E] Commercial �E]Trailer lffouft_,, 0 <br />Motel F] Other -,.,A ------- -------------------------------- <br />Number of living units_____________ Number of bedrooms ----------- �Garba,ge Lind r. ---- ­n�_.LCot Size7' -----_ <br />Number <br />Supply: Public System and name ------------------------------- v ------------------ ---------------------------- Private 11 <br />Character of soil to a depth of 3 feet: Sand'[] Silt ❑ Clay E] Peaf 0-, Sandy Loam -[] Clay Loam'E] <br />Hardpan E] Adobe Fill Material ------------- Wy,es, type __-____________________ <br />(Plot plan, showing !size of lot, location of 'system in"relbtion'to.wells, builclin`'gs, etc.- ust:.be placed onRreverse side.) <br />NEW INSTALLATION: lNo septic tank or seepage pit permitted if public sewer is availabI6 within 200 feet,)'- <br />V , -Ir <br />PACKAGE TREATMENT 'SEPTIC TANK[ Size___________________ ----------------------- ----- Liquid,Depth ------------ ; ----------------- <br />Capacity ----- -------------- Type --"-------I-------- Material---------------------- No. Compartments --------- <br />Distance to nearest. Well ------------ k ----------------------- Foundation _. -------------------- Prop. Line --- ------------------- <br />LEACHING LINE No. of Lines ------------------------ Length of ;each line____.____.____._-_.__.._____ Total Length ----_______.______________-- <br />'D' Box ------------ Type Filter Material�--------------- Depth Filter Material --------- i ----------------------------------- <br />I Distance to nearest: Well -------------- ---- ---- Foundation ------------------------ Property Line ------------------ <br />I ------------ <br />❑ <br />SEEPAGE PIT .___s___ -______________Depth -------------------- Diameter ---------------- N.___s___-______________ Rock Filled Yes ❑ No <br />Water Table Depth ------------------------------------------------ Rock Size -------------------------------- <br />Distance to nearest: Well ________________________________________Foundation ---------------------- Prop. Line ----- ................ <br />REPAIR/ADDITION (Prev. Sanitation Permit # -------- ---------- Date ----------------- ------------------ <br />, ), -, %.0 <br />Septic Tank (Specify Requirements] I ----------------------- ------------ ------ --------------------- ----------------------- <br /><2A r <br />re m --------- <br />Disposal Field (Specify Requir"me�6ts) ---------------- <br />------------- <br />------------------------------------------------------------------------------------------------- ------------------------------------- <br />---------------------------------- --------------------------- ------------------------------------------ ---------------------------------------------------------------- 7 ---------- ----------------------- <br />1. _ - . requirecl_ociclition on reverse side) _V <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 San Joaquin Local Health District. Home 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 shall not employ any person in such manner <br />as to become subject to Workman's Compensation, laws of Colifornia.'i <br />Signed <br />&---------------------------- Owner <br />By Title <br />--- --- ------------ <br />[If other t a wner)- <br />------------------------- <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPT& 6 --e -_411RAI ----------------------------------------------------------------------------- DATE -. -_ ?-. & - - �o --------------------- <br />BUILDING PERMIT ISSUED -------------a <br />f - - - DATE <br />ADDITIONAL COMMENTS ------------------------------------- ------------------------------------------------------------------------ ------------------------ -- ---------- <br />--------------------------------------------- <br />---------- I -------------------------------- ------------------------------------------------------------ ------------------------------------------------------------------------------------------------- <br />-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br />----------------- ------------------------------------------------------------------------------------------------ ---------------- -------------- <br />Final Inspection --- Date --- ------ .`---------- <br />- ------------------ ---- <br />-------------------- --------------------------------------------------------------- <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />E. W 9 1 -'68 Rev. 5M <br />