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FOR OFFICE USE.- <br /> ...... ......... APPLICATION FOR SANITATION PERMIT <br /> Karn fete In Triplicate) Permit No. <br /> . <br /> ............ ....... .......... ...... ........ . <br /> ............. ........­­.-.................. This Permit Expires I Your From Oat@ Issued Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ..--/---- <br /> ...... ...CENSUS TRACT <br /> .......................... <br /> Owner's Name <br /> Address'.._/...k1A-;I V.-.'S 7e-e,A-,4-ty------ ------ -------- ................. .... CI <br /> ty ------ --- .......... ............... <br /> Contra' ----66e740 .................License # Phone--O.VoAgES. <br /> ctor's Name <br /> installation will serve: Residence[]Apartment House 0 Commercial OTraller Court 0 <br /> Motel El Other ... 2- <br /> Number of living units------------- Number of bedrooms ............Garbage Grinder ............ Lot Size <br /> Water Supply: Public System and name ..... .......................................................................................................Private <br /> I LIN, <br /> Character of soil to a depth of 3 feet: Sand Silt 0 Clay 0 Peat 0 Sandy Loam 0 Clay Loam 0 <br /> Hardpan Q Adobe 0 Fill Material ............ If yes,type....... ....... ............. <br /> (Plot plan, showing size of-lot, .16cation of' system In relation to wells, buildings, etc, must be placed an reverse side.),- <br /> NEW INSTALLATION: (No septic'.tank-orAeepag-e pit permitted if public sewer is available within 200 feetj <br /> PACKAGE TREATMENTS f ]- SEPTIC'1. TANX f <br /> ................. Liquid Depth ....... ............... <br /> Capacity -Compartments -._, _-.._.._.-•• <br /> Distance.fo nearest: Well ------/aa...-..............Foundationfi <br /> ............ Prop. Line <br /> LEACHING LINE No. of Lines es ------------ <br /> Length of each line---&'_0----------------1. Total Length <br /> — d, , ill le <br /> 'D' Box 4�..... Type Filter Material .415K.X.41....Depth Filter Material .._.//..... _----_-------_------ %A <br /> Distance-,to..nearest: Well <br /> --45V-- .......... -Property-Line .�...... <br /> SEEPAGE PITDepth ... ........ Diameter ---W._"..... Number ..........at............. Rock Filled Yes <br /> Water Table Depth ----......::;7 <br /> .�..... <br /> ......................Rock size -,..2. K_/.. ........... <br /> Distance to nearest: Well /T`.----------_--.....:Foundation l"..49-- Prop. Line ........... <br /> R EPAIR/ADDITION(Prev. Sanitation I.Permit# -------------------------------------------- Date ------.,_..............__.._...--•) <br /> Septic Tank (Specify Requirements) ---------------•-----------._...---•••-----------•-......... <br /> ............W................................................................. <br /> Disposal Field (Specify Requiren entsl --------- ....... ---------------------_ ........................................................................... <br /> --------- <br /> ------------------------------------------ -------- ------------------•------------••-----------__ ---- <br /> ------------ ....... .................... <br /> ---------------------------------------­-------------------­-­-----------------_------­-m.............................................. ..........................­­...................... <br /> (Draw existing and required addition on reverse side) <br /> 1-hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Healfh;Distrlcl. Home owner or licen- <br /> sed agents signature certifies the following:lowing: <br /> "I certify that in the performance of the work for which thispermit 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 ---­ --d ­44� A--91--------------------------------- Owner <br /> By ------------------------------ �...... <br /> (If other than owner) -------- ----------------.. Jule ................ ................................ <br /> FOR EPARTI <br /> OR EPA, TMENT USE ONLY <br /> ........ . <br /> ACCEPTED APPLICATION ACCEPTED BY ------ e__ <br /> PERMIT <br /> 15SU ....... DATE <br /> BUILDING PERMIT ISSUED ...... ......... <br /> ............................ <br /> COMMENTS <br /> ------------------------ ........... ----------DATE .. ..... ............................. <br /> ADDITIONAL COMMENTS ----------- <br /> -------------. -­.... --------------------------------�1.......I................... --------------------------- ------------------------------------- -------I................. <br /> -----------------------------------------------I - ....... ------------­­­­................ <br /> ................... . - ---------------------------------- ----------- -----------•--..._......_.-_-------------- ----------------- -------- <br /> --------------- ----------- -------------[_ ............. ................. ......--11.......... ....... --------- <br /> Final Inspection by: ............... <br /> -----­--------- ------------------------------------------Date .................. <br /> &v. 5)q <br /> ER 13. 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />