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FOR 6r,FICE USSE: <br /> ....... ............. I k,.... APPLICATION .MR. SANITATION PERMIT Permit No. <br /> f lComplete In Triplicate) <br />............. ............... ..................... <br />..................................................... . Date Issued. This Permit Expires I Year From Date Issued . .... <br /> Application is hereby made ti the SakJociquin Lo6ol,Health District for a -permit-to construct and iastatt the work herein <br /> described. This application_is��mocle in compliance with County Ordinance No. 549,00d exist' Rules- and"Regulations- <br /> ,F1 <br /> .............. <br /> JOB ADDRESS/LOCATION CENSUS.TRACT. <br /> r . f2[_1111wner S Name .............. ........Phone ...... .................. <br /> ..........EYE .........Jrr.................I...................... <br /> Address .... im x-CA ............. city .................. <br /> t--............ ------ <br /> Contractor's Nome ................ --------------------------------------..License # --------- .............. Phone <br /> Installation will serve. s Residence P(Apartment House 0 Commercial :oTrailer Court 0 <br /> Motel n Other ............................................ . <br /> Number of living units:..J... Number of bedrooms ... ....Garbage Grinder .. ...___. ,Lot Size <br /> Water Supply: Public System and name .................................................................Priv' te <br /> ........ <br /> 0, <br /> Character of soil to a depth of,3 feet: Sand !Silt E] Jay ❑ Peat❑ Sandy Loom C1 Clay Loom [,0 <br /> Hardpan 0 Adobe ❑ Fill Material .........._ If yes,type ---------_-----_--- <br /> (Plot plan, showing size of I't, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> .0 <br /> NEW INSTALLATION: (No s 11,ptic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> 1 11 <br /> PACKAGE TREATMENT I j -SEPTIC TANK TA ................. Liquid Depth <br /> OQ <br /> Capacity Type .................... Material...C�W_ __ti_....... No. Compartments <br /> DistaD tance to nearest e Foundation .../.d ........... Prop, Line /AO................ <br /> nce W 11 ..... --------------------- <br /> II <br /> LEACHING LINE C IY No. 'of Lines ............>............ Length of each ........ Total Length <br /> 'D' Box x ..A- . <br /> Type Filter Material ....................Depth Filter Material .............................. ......... <br /> Distance to,nearest: Well ............. Foundation _.ZXZ:......... Property Line ......... <br /> SEEPAGE PIT Dept hi� ... Diameter . 0 - 3 <br /> ......�Wller ---------/­............. Rock Filled Yes ] No ( <br /> Water Table Depth .................._.............4—...........Rock Size ...................... <br /> Distance to nearest. Welty ........................................Foundation .................... Prop. Line ............_.:......7 <br /> REPAIR/ADDITION(Prev. Sanitatiori Permit# ........................................ Date .................................... <br /> Septic Tank (Specify Requir ments) ------------------------------------ ....................................­.................. ............ .......... ......... <br /> DisposalField (Specify Re Arements) .... ....................................1-1........................................... ................. -------------­- - <br /> -----------------------:-------- .......I---------------- ................ -------------r........................ -------------- ........................... ...... ................. <br /> --------------- -------- .......I------------------- ............................1-1............................... ............................I.................... ............. ------- <br /> (Draw. .6z,iiting. and required addition on reverse side) <br /> I hereby certify that I have prepared this application dn&thot the work .will be done in accordance ,with Son .16c. q4lln <br /> County Ordinances, State Lals, and Rules and Regulations of the ton Au-'quin'Locall.Health District. Home owner or-licen- <br /> sed agents signature cerntifies.`16 following: I ,I <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 /> 1� - <br /> as to become subljqcf to WorkmanI s Comps'nsatio'-n-laws. of California." <br /> Signed ---------- ............ ..............­ Owner <br /> By ............................................ ----------------- ............. .Title .... <br /> ............................................. ...... ........ <br /> (if other than owner) - <br /> FOR DEPARTMENT.-USE ONLY <br /> ............ <br /> APPLICATiON':'ACCEPTEDCIIBY il ,xwjr - 1� .... ..... <br /> .............. DATE ..Y.7/1-7t ...... <br /> BUILDING PERMIT- ISSUED...:_..---- ------ ........... <br /> ...................... ..........................DATE ............................. <br /> ADDITIONAL <br /> ............I..........C..O...M...M...E..N...T..S...........!�.................. <br /> .................................**....................I.--..-.-.­...-.------- ............................. ...I........................ <br /> ...............-.-..-.-............................................... <br /> . . ............... <br /> ..... <br /> j( ... .. . .............I...................................................... ----. ...- -- ------------*. .... <br /> . . <br /> ........................................ ----------• --- ................................................... ............ <br /> Final Inspection by: f . F ­ ................. <br /> ..................I. . <br /> SAW JOAQUIN AOCAL HEALTH DISTRICT <br /> E_ H_13 24 1.'68 Rev. Sm ~ 7/72 3 M <br />