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FOR OFFICE USE, lo APPLICATION FOR SANITATION PERMIT <br /> \v,p Permit No. <br /> .......... <br /> �.J (Complete in Triplicate) <br /> ....... .................. ------ ........ Date Issued <br /> This Permit Expires I_Year From Date issued <br />............. ......... ......... ............ <br /> hereby made to the Son,Joaquin Local Health,Distrid,for a permit to construct and install the work herein <br /> Application is e witKICou'nt I y 6idfndinc, 'No, 549, ' d existing Rules and Regulotiorks- <br /> described. This application is made in compliance e <br /> 21 ...... ............CENSUS TRACT .......... ............... <br /> ---------- <br /> JOB ADDRESS/LOCATION ........ <br /> .......... . .....Phone ............................... <br /> .. ..... . ...... ............ ------- ...... <br /> Owner's Name <br /> A .;_2!1�L city .... ......... ... ............................ <br /> Address ........._...............t-n-it... ........... <br /> .......... <br /> 5'Phone -- -------- -- ....... <br /> Contractor's Name ...... -6-- <br /> License #t <br /> Installation will serve- Residence M-4-artment House'o Commercial oTrailer Court 0 <br /> Motelr-1 Other ......... ----------------------------------- <br /> " .................. <br /> Number of living units:..4. Number of bedrooms�_?---------Garbage Grindev,Y.1`7...... Lot Size /,;P A-..-? t <br /> ":71 <br /> . rivate, <br /> Water Supply: Public System-and-'name ----------••--......... ...................................................­--••----•--••---- ..--._.Private' <br /> ......P -1 Lpr,� <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 1771 Ciay E] Peat❑ Sandy Loom o Clay.Loom 0 <br /> Hardpan ❑ Adobe Fill Material A,�If yes, type ........L........... . <br /> [Z <br /> (Plot plan, showing size of lot, location of syst-6.6-,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 feet) <br /> f 2 Size._-............. ------ ------ Li uid Depth ..............I............. <br /> PACKAGE TREATMENT SEPTIC TANK t I <br /> Capacity ..=-Type­._ =�M0teriol......r...... ........ No. Compartments --------­I.......•.. <br /> 1b <br /> Distance to nearest: Well -_.--Foundation ------------_---- Prop. Line ..................... <br /> LEACHING LINE No. of Lines Length. of each line.-.... ......... ..... Total Length ........................ <br /> _n <br /> c1., . --------------Depth Filter Moteriolj,­. .................. <br /> 'D' Box Type Filter Materi 1 1� <br /> Foundation ...... -----------__­....... <br /> ........._ Property Line <br /> Distance to nearest: Well ................••,-.' <br /> so No (DI <br /> SEEPAGE PIT Depth . .... .......... Diameter ....... ------- Number . ......... ...... Rock Filled Ye <br /> Water Table Depth ....... .................... ..............I----Rock Size <br /> Distance to nearest-.'Well -------- -------Foundation ----------- Prop. Line ----_--- ....... <br /> Date - <br /> ....... .... _---------------------- -------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit ----- ----------------- <br /> .. <br /> Septic Tank (Specify Requirements) .... ......... ............. .. .......... ... ..... -------------------- <br /> C <br /> 4V <br /> ......... <br /> .................. <br /> Disposal Field (Specify Requirements) ---dll� . ....... <br /> A <br /> 4. ....... ....... . 4 <br /> - ------- ...... ............ ........... ....... <br /> ... . -------- ------ - <br /> ....................... <br /> .......... ------ ---------------- ----------- <br /> ---------------- Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application <br /> plication and that,,the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules ang. Regulationts 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.f6r which this perm it is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of_California:'" <br /> C71 ----- Owner <br /> Signed ......... -------------------- <br /> "Title ........ <br /> By ------- ---------------- --- <br /> er-than owner <br /> FOR_.DEPARTMENT USE ONLY <br /> DATE -S ...... ­---------- <br /> ......... DA <br /> APPLICATION ACCEPTED BY'..W-­_��U --- ------ ---------- .....-,.DATE ..... .................... ............. <br /> BUILDING PERMIT ISSUED ---------------- <br /> ADDITIONAL COMMENTS .... ......... . ............. -- ------- ------------ .......... <br /> .. .............. .. ...... ------ . ................. ..................... ---------------I.................... ........ <br /> --------------- --------------- ------------- ------ ------------------------------------*....... <br /> ..... .. ------------------ . . ................ <br /> 7 <br /> Date ......7 ..... <br /> ................ ..... <br /> • <br /> Final Inspection by: ... A-V ---- ..... ----- ------------------ <br /> ...............I_—---------- _qL, I �_ <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> 7i72 3 <br /> r LAI 1 24 o-- izAA <br />