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FOR.OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ------------------------------ <br /> (complete in Triplicate) <br /> ..... Date issued _5��l f1411-f, <br /> -- - ------------- <br /> -- ----- ---V___ -i A <br /> . 4 ThIsPermit Expires 1 Your From Date Issue <br /> ------ ---- <br /> ...... ...._I <br /> ---------------------- -------------- -------------- <br /> Application is Fre_reby_Madeto'the SaA,Joaquin Local Health District for a permit to construct and install the work herein <br /> m in_ m Ordnance No S <br /> a r <br /> described. This application is made �n_ with County 0 549 and existing Rule and Regulations: <br /> CENSUS TRACT -------------------------- I <br /> JOB ADDRESS/1-01, ION -------------- <br /> Phone------------------------------------- <br /> Owner's Name ---------- <br /> - ---- ----------------------------------------------------- <br /> :7 -- -- ---------- City <br /> Address -------------------- <br /> ---- ---- ---- <br /> nse A;��7!4-'Phone --- -- ---- <br /> L <br /> ) Lice N <br /> Contractor's Name <br /> Installation will serve. Residence LIA11-6—rtment House,[] Commercial 19Trailer Court 'El t <br /> MotelE]Other --------------------------------------------- <br /> 4��,Z <br /> Gb -6rin" O,er --,JOt,Size ---------- --------------------- <br /> Number of living units:------- Number of�Irooms �, -- _ Private El <br /> - _/-fir <br /> �`- --Garbe <br /> --- — --- --I <br /> Water Supply: Public System^at)d name ---- -- -------------- <br /> Loam <br /> Sand'[]1 Silt El Clay E] peat Ej Sandy Loam -E] Clay <br /> ❑ <br /> Character of soil to of <br /> ,de <br /> pth o� `4 Peat if yes,type ---------------------------- <br /> I Material 11,D_ <br /> --H'a Fd jYdi� <br /> (Plot plan, showing size of lot, location.of system--in rek3flon-jo..411s -buildings, etc. must be placed on reverse side.) Ilk <br /> ewer is available within 200 feetj <br /> NEW INSTALLATION:t (No septic tank or seepage pit permitted,if public s <br /> Size-111�------------------------------------------ Liquid Depth ---------------- --------- <br /> PACKAGE TREATMENT f I ISEPTIC TANK![ No. .Compartments <br /> capacity -------------------- Type -------------L------- Material-------------.-------- <br /> nclation ---- ----------------- Prop. Line ------------- ------ <br /> Distance to nearest: Well ------------------------------------Foundation <br /> i ------------ <br /> LEACHING LINE No. of Lines ------------------------ Length of each line---------------------- ------ Total Length ---------------- <br /> aterial ---------------------------- ---------------- <br /> --------------------Depth Filter M <br /> V Box ------------ Type Filter Material i <br /> .... Foundation ------------------------ Property Line -----_---------­- <br /> ff Distance to nearest: Well -------------------- <br /> - 'SEEPAGE PIT Depth -------------------- Diameter ---------------- Number --------- <br /> ------------------- Rock Filled Yes 0 No .0 <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------------ <br /> -- <br /> Distance to nearest. Well ----------------------------------------Foundation -------------------- Prop. Line ----------- ----------- <br /> ---------- <br /> ---- ---------- - - late Y <br /> n Permit# ---------- <br /> REPAIR/ADDITION(Prev. Sani.tatio ---------------V .0e=;) <br /> ---------- --------------- ------- ---11-1-------------- <br /> Septic Tank (Specify Requirementsl ------------------- - ------------------ --g!5Z 0 <br /> Disposal Field (Specify Requiremons ---------- -- <br /> ------------------------------------------------------------- <br /> t - --------------- <br /> ------------------------ ------------- <br /> - ---------l2e-Z--ow--------------------------I----------------- i <br /> ---------------------------------------- <br /> ------- <br /> ------------ ---------------------------------------- <br /> --------------­------------------------------------------------------------ ---------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done-'in/accoiclance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health'Diffrict. Home owner or licen- <br /> sed agents signature certifies the following—--- - --- - -- - ­ '- ­­ - ' I " <br /> y person itchmariner <br /> "I certify that in the performance of the work for which this permit is issued, I shall not ernploy_an <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---------------- - ------------------------------ ----------------I------------------------------ Owner <br /> - <br /> -- Title <br /> ------------------ ---------- <br /> By ------------------ -- --- - ---------------­-------- <br /> (if c,t r kan owner) -Z <br /> ar, <br /> 016 <br /> FOR_.]DEMATMENT USE ONLY <br /> ------------- <br /> APPLICATION ACCEPTED B`111 --- ---- --------------- - - -- - ----------------------------------------- DATE ---- -- ------ <br /> BUILDING PERMIT ISSUED ------- ----------- -------DATE -------------------------------- ---------- <br /> ------------------------- <br /> ------------------------------------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------- -------------------------------------------------------------------- ----------------_-------------------- <br /> - ----------------------------------------------- -------------------------------------- ----- ---- <br /> ------------------------------------------------------------------------------ <br /> -------- ----- ---- ------------------------- -- ----------------------------------------------------------- ------------ <br /> ------- ----- -------------------- -------------------------------------------------- — -----------___4i <br /> -------------------j---------- ------------- ------- Date ------ _;Z ---------57-- ---- <br /> -----------------------------4? <br /> Final Inspection by - - <br /> SAN JOAQUIN LOCAt-HEALTH DISTRICT <br /> C <br /> E. H,'9 = 1-'6$ Rev. 5M- <br />