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FOR OFFICE USE.: APPLICATION FOR SANITATION PERMIT <br />--------------------------------------------------------- Permit Na7 2 4;1' <br /> . .- <br /> (Complete In Triplicate) ................ <br /> .....................­­­...........­:­-------- <br /> ...................................... ....... This Permit Expires I Year From Date Issued Doti Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit <br /> mit toconstruct; and Install the work herein <br /> described. This application is mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 1_QV1-1PQ_....... ........ CENSUS TRACT <br /> .......................... <br /> Owner's Name ................Cm 2v.HkELLEi�............. .......­­.................... ..............Phone ..... ... .. ............. <br /> .................... C ... .....I............. ......__...... <br /> Address ...... ............ ...... ............. City �Toomxj...... ...P (P <br /> Contractor's Name -------------------- . .......:..............................•---.-.•---......License # ........................ Phone ........ ................ <br /> Installation will serve. Residence(5ApartmentHouseo Commercial C]Traller Court 0 <br /> Motel E]Other ......................... .................. <br /> Number of living units:-,..:I------ Number of bedrooms ....27....Garbage Grinder ............ Lot Size ......................... <br /> Water Supply: Public System and name .------.-• ...................................................................Private <br /> ❑ <br /> Character of sail to a depth!of 3 feet. Sand Ej-__Silt[:] Clay 0 Peat 0 Sandy Loam 0 - Clay Loam 0 <br /> Hardpan [-I Adobe 0 Fill M' <br /> oterial ............. If yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of sysfem In relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage' <br /> :pit .permitted if Lpublic sewer is available within 200 feet) <br /> PACKAGE TREATMENT ' SEPTIC TANK Size.......................... ..................... Liquid Depth .......................... <br /> Capacity -------------------- Type -----------------... Material---------------------- No. Compartments ......................�l <br /> Distance to nearest: Well ....................................Foundation ...................... Prop, Line ....................... <br /> LEACHING LINE No. of Lines ------------------------- Length of each line..........._..._........... Total Length ............................ <br /> V Box ............ Type Filter Material ....................Depth Filter Material ........ ......... ......................... <br /> Distance to nearest: Well ......................... Foundation ..... .................. Property Line .................. <br /> SEEPAGE PIT Depth ..................... Diameter -------------- Number ............................. Rock'Filled Yes [3 No i❑ C� <br /> Water Table Deoth_ ..Rock Size ................................. <br /> Distance to nearest-. Well ---------------------------- ............foundation --_--_---------- Prop. tine ........................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...... ............................. ....... Date ............................... <br /> Septic Tank (Specify Requirements)- ------ _Ck ............................ <br /> Disposal Field (Specify Requirements) ------------------------------------•-------...---- ----------------- .............................................. <br /> --------------*------------- ............. <br /> --------------------------------I--------- --------------- --------------------------------:--------- ............. ----------- --------------------- ...................... <br /> (Draw existing and required addition on reverse side) <br /> I :hereby certify.that I have prepared this application and that the work will L be. done In accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Sao Joaquin Local Heci1W District Home owner or Iltew <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 bec!T " r re's Comperes q q�ol �1 I <br /> ;;b�jt to. o k �;rs of California." <br /> .........7 <br /> __ ___ ... 7 <br /> Signeclo)C -- --------------------- .. ..... ----------. Owner <br /> By ............ -------------------------------------------------I--------------------------------------- Title -------- ........................... ...... <br /> Ilf other than owner) <br /> FOR DEPARTMENT SE ONLY <br /> APPLICATION ACCEPTED By --- -------------- ----------- DATE ............. <br /> BUILDING PERMIT-ISSUED ........ <br /> --------- --- DATE .... <br /> ADDITIONAL COMMENTS --------------------------------------------------- —------------------- <br /> ........................ ...........I——............. .... ............................... <br /> --------------------------------- -------1---------------------I--------------------- --------------- .............. -----­--------- ..................... ----------- <br /> -------------------------------------------- ------ -------------------------------------------- ---------------------------------------------------------- .................. <br /> 4.................... --------------------__--.....-----•---- ............ <br /> . . . . .... ------------�� ---------------------- - <br /> Final Inspection by- ---- ­­................ . ...... .... . M-/------Date - Z- ---­-----­------------------­------ <br /> - <br /> E 13 2h 1-68 &_,v. 5M SAN JOAQUIN LOCAL HEALTH 6vsfiICT 8/7h 3M <br />