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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -17 <br /> ---------------_.......... -to in Triplicate) <br /> 1comple Permit No. ................. <br /> .......... <br /> ............................... <br /> ........ This P&rmit ExP IrOs I Year From Date 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/LOCA, <br /> :.JTI .. ....................... <br /> Owner's Name ............... ..........._CENSUS TRACT ......... .......... <br /> -- ---- ------------ .............. ............. ........................... ....................... <br /> Address <br /> ... ....... <br /> r .........City .. .... <br /> Phone .............................. <br /> ..................... ............... <br /> Contractor's Nome <br /> --- ------- ........License # ... ............ <br /> Installation will serve: Residence ..Apartment HovsefCommerc'lal CITraller Court <br /> -Mote!.0 Other ................. <br /> ..................... <br /> Number of living units:___-)__ Number of bedrooms'-'3-_---.Garbage Grinder ........._ Lot Size .......... ...... <br /> I <br /> Water Supply. Public System and name <br /> ........I.... .........Privah <br /> Character of soil to a depth of 3 fe <br /> et: Sand El Silt[3 clay C] Peat.[3 Sandy Loom y Loom 0 <br /> Hardpan Adobe 0 Fill M6terfal ............ 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 /> .INSTALLATION: (No septic tank or seepage pit permitted-if public-sewer Is available within 200 feet,) <br /> PACKAGE TREATMENT f J SEPTI• C TANKi a Size................................................ Liquid Depth ................... <br /> Capacity <br /> --------------- Type------ ....... <br /> Materia)..._....._............ No. Compartments <br /> Distance to nearest: Well ................ <br /> ......... <br /> .�- I I.. I , , .1 ....................... • <br /> Foundation ...................... Prop. Line ....................... <br /> LEACHING LINE - -No.- of tines-�-!.� 1, ' <br /> -------- Length of each llnlp........ ................... Total Length ............................ <br /> V Box -------- Type Filtbr Material ....................Depth Filter Material ...... <br /> .......................... <br /> Distance to nearest: Well ---------------- ------_ Foundation ........................ Property Line ......................... <br /> SEEPAGE PIT Depth I - <br /> --------------- Diameter ................ Number ---------------------------- Rock Filled Yes 0 No 0 <br /> i <br /> Water Table Depth .......................... Rock Size .......... <br /> I ___­----------- ................. <br /> Distance to nearest. Well ......................... ..............Foundation .............. Prop. Line ........... ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _........__.....-,___._•• ----------_------ Date <br /> Septic Tank (Specify Requirements) -------- <br /> ................ ....... ............................................ ............... ...........1, <br /> Disposal Field (Specify Requi <br /> rements) -------- <br /> ----------- <br /> 7 <br /> --------------------­- ......... .......................... <br /> - <br /> -------------------------------------------- <br /> ------------------------­-----07----- ------------- <br /> 1113raw existing and required addition. .- . .-a-n..reverse- .- side} <br /> -, ----- ........................................................ <br /> I hereby certify that I have prepar1q� !d this application and that the work will be done In accordance with Son Joaquin <br /> or or licen- <br /> sed agents signature certifies the following. -District. Nome own <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health <br /> "I certify that in the performance ofthe work for which this permit Is issued, I shall not employ any person In such manner <br /> as to become subject t.a Workman's mpensation laws of California." <br /> Signed ----------------- <br /> ------------------ <br /> By ------- --- ------------------ Title <br /> (If otherthanowner) _-_ --- ------------- ---------- <br /> FOR DEPARTMENT USE ONLY <br /> %J <br /> APPLICATION ACCEPTED BY <br /> ........... <br /> ---- -- _- -------­DAT7F ... . <br /> BUILDING PERMIT ISSUED --- - -------------------------- ........ ........... <br /> ADDITIONAL COMMENTS ..... . ............. .. ..... <br /> ---------- -------------------------------_....... ----------------------DATE <br /> ------- ---- <br /> ----------------------------------------------------------- ------------------------------------•---------•---• <br /> ----------------------*-------------*----------------------------------------------------*-----------.............. .......... <br /> ---------------- -------- -------------- ---- -------------------------------------------------------------------------------------------- ........ ....................... .. -------- <br /> -------------*---------------*------------*----------------- <br /> - <br /> --------------------------* --------------------- -------------------- <br /> ---------------------------------------- :g ............ __ <br /> Final Inspection by: ........ ------------------------------------------- <br /> --------------------------------I.................................Dote ...... <br /> EH 13 2h 1-68 lieu'ell -- ---- - .-I.., .............. ..... <br /> . <br /> 514 SAN JOAQUIN -LOCAL HEALTH DISTRICT <br />