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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> . .1 <br /> (Complete in Triplicate) Permit. No. .. ............. <br /> ........................ ................. ! <br /> .......................................................;. .i This Permit Expires I Year From-Date Issued <br /> Dote Issued ./-7- 76 <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 mod6 in compliance with County Ordinionce, No. 549 and existing Rules and Regulations.. <br /> JOB ADDRESS LOCATION ........Lznx& <br /> Owner's Name ......... ... <br /> ............. ..................................Piione .............................. <br /> Address <br /> .... .. .. ................ city -------- ................... ................ ....... <br /> Contractor's Name <br /> -/. ........... # ..... Ph-one <br /> Installation will.serve- Risidence,23Ajp'artment_House0 Comr-herciol :E]Traller Court 0 <br /> ........... <br /> Motel 0 Other —... ................ <br /> Number of living units_____________ Number of bedrooms ..3_._.__Garbo' <br /> .....Garbo'ge.6r"fin-der ------------- Lot Size .._.__..........................__.__...___• <br /> Water Supply. Public System and n I ame...... ........._........ ..............................Private <br /> I --------- ­_­❑----I------------ - <br /> .. <br /> Character of soil to a depth of.3 feet: Sand❑ Silt Clay C] ' Peqf[�] 'Son'dy Loom C]. Cloy Loam 0 <br /> Hardpan E] Adobe C] Fill Material if yes, type ......................... <br /> (Plot plan, showing of lot, location of .system in relation to wellt,,buildings, etc. must be placed on reverse side.{ <br /> NEW INSTALLATION: IIj <br /> (No septic tank or seepage p!t p�ern2�ittt�,If py�blic sewer is available within 200 feetl <br /> .1 _._ _ _ _ _ — X <br /> PACKAGE TREATMENT SEPTIC TANK'f I Size________________ __- <br /> .......... Liquid Depth _.......... ............00 <br /> Capacity ................. Type ............ rMaterial-..................... No. Compartments ................ <br /> sian-ce. toi nearest. Well .....................................Foundation .................I Prop. Line ...................... <br /> LEACHING LINE t J No. of Lin6s .................. Length oif_ea'c�h' line............................ Total Length ..... ........ ......... <br /> ;I'__r — - --- <br /> V Box ............ Type''Pilter Material Filter Material ..................... ................... 0 <br /> Distance to nearest. Well <br /> ...................I... Foundation ... .................­ Property Line ---_.................. <br /> SEEPAGE PIT Depth Diameter ...... ......... Number ... ..................... Rock Filled Yes No ❑ <br /> Water Table Depth .............*­­­'­'r-------*......*.......*Rock Size ................................. <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line .................... <br /> REPAIR/ADDITION jPrev. Sanitation'Permit ....................................... Dote ................................ <br /> i <br /> Septic Tank (Specify Requirements) -------- .......... ................. <br /> .4 ...I........... ...... <br /> ........I. <br /> ... <br /> D' os [ Field (Specify RequirementS) .... __ I • .. <br /> ...... . .... <br /> dap-------------------------------------- ........................... ...................................................................... <br /> -------------------------------------------- ...... ------------------------------------------------------------------------------------ ...................... .................... <br /> Prow 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 omp�ioy any-person.in such manner <br /> as to become sub' t to Workman's'Co.mpensation laws of California." <br /> Signed ......... .... . ...........................-.- Owner- <br /> By .... <br /> ---- -- ---- ................... <br /> ---*.......... <br /> _ .. ....... ----------------- ------------------------- Title CC,� .. -_/. <br /> . . <br /> If oAe_r't'hon owner)-' <br /> OCIR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ---------- -------------- ................. DATE.2_74 <br /> ......................... <br /> BUILDINGPERMIT ISSUED .............. ...........:................:•-••-`------- ....................__----------DATE .......... ...............:.............. <br /> ADDITIONAL COMMENTS .............. .......... <br /> . . ........................................... .................. .............. ....... ............. <br /> E <br /> ...............................___.....................4................*...... -......-_•----.__----................................................ <br /> .............. ....... .. ............................... <br /> ------------I.................................. ....................................... ------------------------------------------------------ ......................... <br /> ........................... -------------- <br /> ---------------------- ....g-�74........................ <br /> Y1. ...... 0 .................... ..................................................Date ............ -------------------------- <br /> inal Inspection b <br /> ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH, DISTRICT <br /> E. H.13 24 1-'68 Rev. 5M 7/72 3 14 <br />