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FOR_OFFICE use: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------- .............. <br /> lCompleto In Triplicate) Permit No. <br /> .........:..:.............•---•--- <br /> Date Issued <br /> ........................................................ I This Permit Expires I Year From Date Issued <br /> Application Is hereby, made tollthe Son 11oaquin Local Health District for a permit to construct and install the work here'lin <br /> described. This application is made in'compliance with County Ordinance No., 549 and existing Rules and Regulations., <br /> JOB ADDRESS/LOCATIQN ...... ..........I......CENSUS TRACT ................. <br /> ................ ..............Phone 7c)... <br /> Owner's Name ------ - ------- . ...................................................... <br /> Address -.......... ....................­..........I City ... <br /> ............ ......... <br /> Contractor's Name 414 ... ....... .. ..........!!��-------­-------- ............License # Phe Nom.. <br /> Installation will serve.- Residence 0 Apartment Housef] Commercial OTrq(�WCourt 0 <br /> APO <br /> 4 <br /> Motel 0 Other..� ..................... <br /> : <br /> Number of living units:_..__.__ Number of bedroorps ....Garbage-drinder ..........._ Lot.. Size ............. <br /> wee <br /> x <br /> A� <br /> e7 <br /> Water Supply. Public System and name ......... ...% ....... — <br /> .............. ' ...............................Private 0 <br /> Character of soil to a depth of 3 feet: ',Sand E3 Silt[I Clay 0 Ped!0Soq#y Loam 0 Clay Loam 0 <br /> Hard an 0 Adobe Fill M6terlol if.y6s,typ9 —....... .......... <br /> (Plot plan, showing size of lot, locoticn of system in relation to wells, b6ildings, 'etc.-must:be placed on reverse sId6.) <br /> fi <br /> NEW INSTALLATION: (No septic tank or seepage..pit,perm Itted If public S er Is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK f q' ......... .......... <br /> 11 S I Size...... .............. ...... u d Depth ....... <br /> $ <br /> .......... No. ................ <br /> Capok.dl <br /> Capacity ..------ ------ _---------. Material. Compartments <br /> V Prop. Line ..................I_- 00 <br /> Distance to nearest: Well ---- ............ ...............is I Fd66clatio' <br /> .............. <br /> LEACHING INE ('X .............. ............... <br /> No. of Lines --------------- Length of each lin' ...... ,TotalLe'rigth ..... ...... <br /> X, <br /> iT Box ...... Type-Filter Material ---_-----------I-.Dipth 1`04i'Material .......................... <br /> .................. <br /> Distance to nealresfi. Well ..... .................. Foundatild� --------- ---------:.... Pro ...... <br /> Depth Diameter --- We'!:..............�:.......... <br /> SEEPAGE PIT ------------ ------- ............... Numbers Rock Filled Yes [3 No 0 <br /> Water: able Depth" ......... .................. c Size ....................... ........ <br /> Distance to n -rest.' .............. .. ................ <br /> ea Well ..... .............. i F06hdation Prop. Line ......... ........ <br /> REPAIR/ADDITION(Prev. So nit4tion Perm It ..K...... ..........•-•- -....._...........IData ... ................I <br /> Septic Tank ;Specify Require'meni <br /> . ....... ` ..441 ------------ <br /> Disposal Field (Specify Requirements) A _33�---%2, .......§9k <br /> A1-------_-----__------ .................*------------- <br /> :IiI <br /> ---------------------------- ----------- ........­...... ............. ...................I..................................................... ........................ <br /> ------------------ <br /> :---------------- i[----------- ........I------- ----------- --------_-----_---- ......_.­.......I...........I......... .............­ <br /> lDra'w existing and required addition on reverse side) <br /> I hereby certify that I have oilipaivd this application and that the work will be done In accordance with San rJoaquin <br /> County Ordinances, State Laws, and We's and Regulations of,the Son Joaquin Local HealtW'Distrld. Horne ownwor' licen- <br /> sed agents signature certifies the following- <br /> "I certify that in the performance of thg" workfor which this p_!Lrml1Lks.Issued,J..sb_qlf-not-.Omploy-,any-perion.in.,,such,manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ........ ----I.... ... r <br /> .... ..... . ........ ............. Owner <br /> _4 .. ..... . . . ......... Xitle ... <br /> By ...... <br /> ........................ <br /> Of other than owher) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .1 �__4111........ .......................................................... -------- DATE ---_------- <br /> BUILDING PERMIT ISSUED __k!--- -----------------­------ ............. ...........................................:_.._DATE ........... ............................ <br /> ADDITIONALCOMMENTS -------;�-------------_---- ----------------------- ........................................_------_--------------__------------ ........................... <br /> ----------------------------------------------- ---------------:......................... .................................................................................... <br /> ----------------------------- --------------------------------------------- <br /> -- --------------------------------------------------------------*--------- <br /> iI <br /> -­---------------------------­­.------------------------------------------------ ...... . ................... ............ -- ---------------------r <br /> Final Inspection by. ..............._.!M__.._... _ ---------------------- .. ...... .............Date ...... ..........I.......... <br /> - - - ------- <br /> EH 13 2h 1-68 Rev. SAN JOAQ I OCAL LT STRICT 8/74 3M <br />