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FOR OFFICE USE. <br /> APPLICANI�ION FOR SANITATION PERMIT <br /> .7 <br /> --------­1...... ........ —�6rmit Na--------------_ <br /> (Complete in Triplicate) <br /> ............... .................... <br /> Date Issued <br /> ....................... -\ -.ihisPermit Expires-'-l .Yqar-,tro #,Issued <br /> Application is hereby made to the Son Joaquin Local Health District fora 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 .............CENSUS TRACT ........ .............. <br /> ...... ------------------- ......................................Phone..............._._............. <br /> Owner's Name ...... ---------------- <br /> s <br /> Address ....... --------- --------------------------------,.......*........ City _....•....---••-•--•-•.._._.._...;....j..... <br /> I llv�_ - , Phone <br /> ;;6PA111V .......................I.......-..License # <br /> Contractor's Name <br /> Installation will serve: <br /> Residence J&Apartment House 0 Commercial :[-]Trailer Court 0 <br /> Motel n Other ................................... <br /> Numberof living .units:---,1_.., eroms _,Y.....Garbage Grinde _V944$ <br /> INumber of bedrooms rIZ5- ... Lot Size <br /> Water Supply: Public System and name ......................................................................... ...................................Private <br /> Character of soil-lo a depth of 3 feet. Sand[I Silt❑ Clay [] Peat E] Sandy Loom Clay Loam C] <br /> Hardpan ❑ Adobe Fill Material ............ 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 feet,} <br /> PACKAGE TREATMENT .1 TANK 0 Size. Depth ...-------- <br /> 0.................... Liquid D ...... <br /> Capacity .. . .... Material_44Y-1-1 No. Compartments ........ <br /> 'Distance to nearest: Well --7.-,l.........................Foundation ./A.1.......... Prop. Line .............. <br /> LEACHING LINE Pd No. of Lin e <br /> s ------49--..._....-.. Length of each line.... .................. Total Length ZA�_'.* ............. <br /> i <br /> /�604eA 01 14,'D' Box X46..- Type Filter Material, repth Filter Material ./If...... ......_:�...... <br /> 40' <br /> 0 1w . 1 ....... <br /> Distance t' nearest: Well __41Ko............ Foundation .. ........... Property Line 195 <br /> '04-1 & A <br /> SEEPAGE PIT Depth -0.0.-------... Diameter _______ Number -----�?....................Rock Filled YesNo C] <br /> t I <br /> -Table Depth ...................Rock ck Size .......... <br /> .Distance to nearest: Well ....Z. ..........._.....Foundation ........... Prop. Line __o?*....... <br /> REPAIR/ADDITION"(Pi,rev. Sanitation'Permit# ........... ------- ........... Date ....... ................... <br /> J <br /> Septic Tank (Specifykeq u re ents) ..................... ........ ... <br /> .......................... ... ............---•-•-----•._._.____.-_-...-_._.._•...------------.... <br /> Disposal Field (Specify Requirements) ............ ................ Zlo,-------------t.................................. ............. <br /> X <br /> --------------------------­ ---------------------------------------------------------------------------------------- ......................­­................................ ........................ <br /> ...................... ----------------------------------------------------------- .,;-- --------------------------------------------------------!--------------------------------- <br /> (Drdw existing and required ocid'i'tion on reverse side) <br /> I hereby certify that I have prepared this application and at the work will be done in accordance with Son Joaquin <br /> C,ounty Ordinances, State Laws, and Rules and Regulations of the San 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 whichltiis permit Is Issued, I *hall not employ any;person in such manner <br /> as to become subject to Workman's Compensation laws of'C!Q1IifornIa.','._,..__. <br /> Signed ----------- - ----- ................. Owner <br /> By ........... ...... <br /> -------............. ....... Title ...... ............ ............ <br /> . ....... ----------------- -W <br /> (If er than owner) 4 FOR DEPARTMENT USE ONLY <br /> -8 --- ................•_•,:..,., PATE T!77.... <br /> APPLICATION ACCEPTiD _Y�__ ........ ... ......DATE ......... ............ <br /> BUILDING PERMIT ISSUED ........................ .......... " - ­ : <br /> ADDITIONAL COMMENTS . . ...�..:...... .. .•.• <br /> .......... .... ....... ......................... ...... ........................ <br /> ...................... <br /> I......... ae. <br /> . .. .. 7t <br /> 7Lt... ....... ..e <br /> e_ <br /> 6- <br /> ...... . -- ........ <br /> ic .... .. <br /> Fidal' insp io ....... . . ........... .. )ate ............. <br /> SAN JOAQUI LOCAL HEALTH DISTRICT <br /> E. H.13 241-'68 Rev, 5M 7/72 3-M <br />