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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ....... Permit No. <br /> {Complete in Triplicate) <br /> ..................... ....... ............... This Permit Expires 1 Year From Dati1isuied <br /> Dote Issued .'/,_Z'..'7,.S. <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 ---wpa:ne.., <br /> .................-...._._..----........CENSUS TRACT ......... ...... ...... <br /> Owner's Name .......x <br /> -----47.1,ke'llk./------------- Phone <br /> ................ .................... <br /> Address ......... ..fir._.............. <br /> ................ ........ ................................... <br /> Contractor's Name ........ :!IIKOVA� ........ ----_---------------License Phone *.1wMet <br /> Installation will serve: Residence 0 Apartment House 0 Commercial OTrailer GO&W <br /> Motel0 Other ......:.........•-•--- .................. <br /> Number of living units,._/---- Number of bedrooms -..F.....Garbage Grinder IVAP... Lot Size .............. <br /> Water Supply. Public System and name .............. ......... ----------------------_-----------------_-------__....... ..............Private gr <br /> Character of soil to a depth of 3 feet: Sand❑ Silt[3 '/Clay 0 Peat(i Sandy LoomA Cloy Loom 0 <br /> Hardpan ❑ Adobe ❑ Fill M6terial --_------- If yes,type ..... ---------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feetJ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ------- ......... Liquid Depth V-2-: .................. . <br /> Capacity/ Type ... MaterioJ.d0/111,(_..-._._. No. Compartments ............. <br /> Distance to nearest. Well .............. ..Foundatioh Prop. Line ......... <br /> LEACHING LINE No. of Lines _11, .........1_ 1ength of each line.. ................... Total' Length -XIP................ <br /> 'D' Box Type filter Material 1t44646 Depth Filter Moteri@-4/wAt�:)/.................................. <br /> Distance to nearest- Well /9- _ ........ Foundation.. ........... Property Line .... ........... <br /> �rr <br /> SEEPAGE PIT Depth .................... Diameter .............. Number _------------------- Rock Filled Yes E] No I C1 <br /> .............. .......... . <br /> Water Table Depth .......... ................ ...........a—.....Rock Size ........ <br /> Distance to nearest: Well .....................................,—Foundation ........_:......... I Prop. Line ..................... <br /> REPAIR/ADDITION(Prey. Sanitation'Permit 0 -------------------------------------------- Date <br /> ..:::............••------........J <br /> Septic Tank (Specify Requirements) .................. .................... <br /> ----------------------•---•-•--......-'- .............. ................. <br /> Disposal Field (Specify Requirements) ..... ............... .......................................................7,-.........................=-•..._..---....------------ <br /> -••-------.---•--------•--•---•-------------------- <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 accordance-with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <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 become subject to Workman's Compensation laws of California." <br /> Signed ......... ---------------- <br /> Owner <br /> 4' <br /> By ........... op, <br /> ......... .............. <br /> I.f. .0.�eh than <br /> Title ..... <br /> -------- ---------------------- <br /> n owner) <br /> FOR DEPARTMENT USE ONL* <br /> APPLICATION ACCEPTED BY ...C_, �­t, '.. 171)J.#1' <br /> ........­.......... -------- ...... .............. DATE ....... ............. <br /> BUILDING PERMIT ISSUED ................ ............... :. , <br /> ............ DATE .......I................. ............... <br /> ADDITIONAL COMMENTS ................. <br /> .............................................. ................................................ .................... <br /> ............... ......... ....................... ........ ...... .............. <br /> ......................__------------------ .................I........... ............... .......... .......... <br /> ...........::......--•----•-•-•--•--- <br /> ...-•---- <br /> t........................ ....................... <br /> ......... . -•-......-•----•--------•....-•................... ....... ............. .......I <br /> Final Inspection by: ........... <br /> 6": - - - -------------------------------------------—................................ ate .... ....... ---------­ <br /> -' "JOAQUIN LOCAL HEALTH DISTRICT <br /> ...........­......................­............. <br /> N <br /> C u 13 24 n_ <br />