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FAR OFFICE USE: -AJ APPLICk-TION-FOR SANITATION PERMIT P.ermit No.. <br /> .....*e <br /> ..*ewxn <br /> (Complete in Triplicate) <br /> --------------------------------- Date issued -01-12- <br /> This Permit Expires I Year From Date Issued <br /> ------ ---- ------- <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> d Regulations. <br /> described. This application is made in c Ilan Ith C ce <br /> Ord' 0.nty 0 d' . N ' 549 and existing Rules an <br /> CENSUS TRACT ----------------- --------- <br /> JOB ADDRESS/, CATION <br /> ------------ <br /> ---------------- <br /> Owner's Name -----LJJ-N --- ---------------------------- -----------------------------Phone ------------------------ <br /> ----------------------- ----------------- <br /> -- <br /> - -------------------- city -------------------- <br /> Address ---------------- -----.License Phone <br /> Contractor's Name -----( - ----- <br /> Installation will serve: Residence P-K�p�a�rtment House F1 Commercial [-]Trailer Court 'El <br /> Motel F-I Other -------------------------------------------- <br /> Number of living units:___ __ Number of bedrooms ----- ------Garba-ge Grinde(r------ Lot Size X--`-'-7�a3'-----•----• <br /> Number <br /> Supply: Public System and name ................................... ----------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Scind'E] Silt 0 Clay E] Peat F -1 <br /> I Sandy L6bm -F Clay Loam[] <br /> Hardpan F-1 AdobeV Fill Material --AAA-- If yes;type ---------------------------- <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 /> PACKAGE TREATMENT I I SEPTIC TANK' Size-------- ------------------ Liquid Depth ---------�4 ------- <br /> ypeVq ----- --------- b <br /> Capacity ..... T Material No. Compartments <br /> Foundation ----------- Prop. Line ----&-------------- <br /> Distance to nearest. Well <br /> 9t --- ------- - <br /> of each line---g� ? ------ Total Len h <br /> LEACHING LINE No. of Lines --------- ------ Length <br /> Type Filter Material ith-,Filter Material ----- ------- - <br /> Distance ------- Foundation <br /> 'D' Box ell Line ------------------------ <br /> t nearest. Well ----- -- ------------ Property <br /> u-M-b e <br /> °" ------ ---------- Rock Filled Yes No <br /> SEEPAGE PIT DepthZ <br /> -------- Diameter ------ Number <br /> Water Table Depth --------(%1-------------------------------Rock Size -------- <br /> Distance to nearest.. Well ------/47:�-----------------------Foundation ------ Prop. Line --/----------- <br /> REPAIVADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------- -------------- <br /> I 1� 1 — - -----i-------- <br /> ------------------------------- -------- -------------- <br /> Seplic ank (§pecify.?i�qVirements).-- ---------------------——----------------- 71 <br /> Disposal Field (Specify Requirements) -------------------------------------------------------------------- -----_ <br /> ---------=------------------------- <br /> ------------------- -------------------------------------------------------------- <br /> ------------------------------------------------------------ <br /> ----------------------------------------------------------------------------- ---------------------------------------- 7---------------- ------- <br /> k --------------------------- <br /> -------- --------------- - <br /> ---------------------------------------------------------------------------------------------------------------------------------------- ------__ <br /> (Draw <br /> -(Draw existing and required addition on reverse side) <br /> - <br /> I hereby 'certify that I have prepared this application and that the work will "be done in accorda;�cewith Son Joaquin <br /> County Ordinances, Slate laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or liven- <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 /> Signed ----------------------------------------- ------------------------------------------------------ Owner <br /> ------------ <br /> By ----------------------------- ------------------------ Title <br /> (if otherthano ed i�' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------- ------ - ------------- -- ----------------/ - --------------------- ------ TE ----- <br /> -------------------------- <br /> w i N; DATE -----0,o----- o------- ----------------- <br /> BUILDING PERMIT ISSUED ----------- -------- - <br /> ADDITIONAL COMMENTS ... <br /> --------------- --- ------------------------------------------------------------- <br /> ------------------------- -------------------------- --------------------------- <br /> 1�� -------- -------------------------- <br /> -- -- ---- ----- - ------------------ ------------------------ <br /> .. ......... <br /> h--Vs--- - -- ------------------ ---------------------------------------------------------------- ---- 4------- ----------- ----�-I- ------ <br /> ---- --------------------------- --- -------Date ... ----------------------------aL::-:-- <br /> ----- <br /> Inspection by: --------------------- - I 1� .1 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTS jr <br /> E. H. 9 1-'b8 Rev. 5M <br />