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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> . I I Permit No. ....--.- <br />..........................._......•_..._...._.._....... (Complete in'Triplicatel <br /> ................... ..............I Dote Issued <br /> This Permit Expires I Year From Date Issued <br /> ...................I....---------•-_.._.... <br /> V, <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. ThisRules <br /> application is made in compliance with County Ordinance NO. 549 and existing es and Regulations. <br /> .CENSUS TRACT ...... ........... <br /> JOB ADDRESS/LOCATION <br /> .............Phone <br /> Owner's Name .......... <br /> Address ....................5,:4-2--le----------_---- ....... ...... ......... ----------- ............ city ...........A--------•. .................... ............................... J; <br /> License # ........................ Phone ... .......................... <br /> Contractor's Name ...... -,g, <br /> le-bi------------ ---------------------------------------------------- <br /> Installation w.ill serve: Residence o Apartment Houseo Commercial oTrailer Court 0 <br /> Motelj;!rbther .... <br /> arbage Grinder ------------ Lot-Size ----- ...................................... . <br /> s-------_---- Number of bedrooms ............G <br /> Number of living unit ........Private 0 <br /> Water Supply. Public System and name ....................Sand 0 Silto Clay El C].....r ............ ......---------- -_-----_------ .........7--- <br /> Peat Sandy Loam ❑o ..,Clay Lootn.0 <br /> Character of soil to a depth of 3 f6et. - <br /> Hardpan E] Adobe 0 Fill Material ..........­ if yes,type .--------_---------------- <br /> relation to wells, buildings, etc, must be placed on reverse side.) <br /> n <br /> "(Plot plan, showing size of lot, location of. system 1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feetJ <br /> ..................... <br /> TIC TANK( I Size...-•--•-........................... <br /> ......................... Liquid Depth -.... <br /> PACKAGE TREATMENT ,I 3� <br /> . P <br /> TIC <br /> Capacity ..................... Type ------- ............ <br /> { Material--------•............. No. Compartments <br /> Distance to nearest- Well .........4..........................Foundation ...................... Prop. Line ..................... <br /> • <br /> LEACHING LINE No. of Lines ........................ Length of each line.--------------------.-----� - Total Length ........................... <br /> 'Material ................................... -------- <br /> Material ...........Depth Filter <br /> V Box ..... ------ Type Filter <br /> Distance to nearest: Well ......................•• Foundation ........................- Prop" Line ....................... <br /> Number11 .......... Rock Filled Yes o No <br /> SEEPAGE PIT Depth .............. Diameter -------------— .... --------_-- <br /> WaterTable Depth ................................ ......i........Rock Size ............................ <br /> Distance to.nearest- Well ........................................Foundation........ ............ Prop. Line .............. ....... <br /> REPAIR/ADDITION(Prev. Sanitot ion'Permit# ............................................. Date .................................. <br /> .......... ....................... ......... ..........7--- <br /> Septic Tank (Specify Requirements) _---------------------- - <br /> Disposal Field (Specify Requirements) ....... ...... <br /> ............. <br /> -- -------- -------- A I <br /> •----....._._--- <br /> .. <br /> ------------------------------------ --------------- ---------- ............ ---------- <br /> ------------- - ------ ---3---------- ............................d';i'iion on reverse side) <br /> (Draw existing and required a <br /> I hereby *r or ficon- <br /> certify that I have prepared this application and that the work will be done in-accordance with Son Joaquin <br /> and Rules and Regulations of the Son Joaquin Local Health District. Home own <br /> County Ordinances, State Laws, <br /> sed agents signoiNre certifies the following: permit is issued, I shall not employ any person in such manner <br /> "I certify that in the performance of the work for which this <br /> as to become subject to Workman's Compensation laws of California. <br /> Signed <br /> BY - - -------------•---•------........---•-•••...._------ Owner <br /> ( <br /> .......I................... ...... <br /> ... ....... . Title ..-------------------------------- <br /> .... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> FE 7�7� <br /> D, E. <br /> .............­ DAT .. ... . -- -- ---- - .............. <br /> APPLICATION ACCEPTED BY --- -- ------- ...................--•........--•.............. ... <br /> .............. <br /> ................................. <br /> ............................ <br /> ;v7 ........................... ......................... . ........................................... <br /> BUILDINGPERMIT ISSUED ............... .......................................... ............................................DAT <br /> ADDITIONALCOMMENTS ..................... ................................................................. ................................................... <br /> ...............I—.......... .........................................................................7----- <br /> ..................................................................................................... <br /> ............I.................. <br /> .. . ....................................................... �P__;� _. ..�-- -------- <br /> ........Date <br /> --------------------;4............I-------*.........­*......................... <br /> SQ....................... ...... .. . ....... <br /> FinalInspection by: .............. .. - -------- .. ............­.­........ ---- --- .............................. <br /> '"AN JOAQUIN L 4 HEALTH DISTRICT <br /> 91L I -An n- CLA 7/723 <br />