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FOR OFFICE USE: <br /> n APPLICATION FOR SANITATION PERMIT <br /> ................. ..i! . <br /> ..........._........_. (Complete in Triplicate! Permit No. .�......... . <br /> .s .:_a:3_:7 <br /> ......................................................... Thts PermitExptros 1 Year From Da <br /> tis Delssued Date issued 7 <br /> Application is hereby made to the San 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 .._.!A/'-i•t'. ------ .......... ®rc. ...................... ....................CENSW TRACT .......................... <br /> Owner's Name ................... f.��. ------------....--•---.........---....._.......-..._....,........................._-.._.-_--_•Mono .g_33 `57� - <br /> . <br /> Address ............_. �.9`1 �S_ <br /> . .. S':o.._R,jd r r.......................City <br /> Contractor's Name ._. .......................-----_--•_._ .............Licensed -_ 3S 6S7 - <br /> -------------- ---------------._............_ ...._..._....__....._.__ phone . �-------•---------1- <br /> Installation will serve: Residence[Apartment House Commercial oTroller Court 0 <br /> Motel ❑Other............................................ <br /> Number of living units------------- Number of bedroomt ...1 --Garbage Grinder _--_-_-_--_ Lot Size ---_- ...................................... <br /> Water Supply: Pubic System and name ......... . .... .... ............ .................. ...........................................Private Q- <br /> :-......_....._ <br /> Character of soil to a depth of 3 feet: Sand Siit Q CiayA Peot Q Sandy Loom o Clay Loam Q <br /> Hardpan Q Adobe 0fill Material ............If yes,type............... ............ <br /> (Plot platy, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION: (No septic tante or seepage pit permitted If public sewer Is available within 204 feat,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK£ ) Size................................................ Liquid Depth .......................... 9 <br /> Capacity -------------- _-- Type .................... Material---------------------- No. compartments ------- <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... _J <br /> LEACHING LINE [ j No. of Lines --------- ----------- Length of each line............................. Total Length ............................ <br /> 'D' Box .._..._ .... Type Filter Material ....................Depth Filter Material ............................................ ,(1 <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ , <br /> SEEPAGE PIT [ ) Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No <br /> Water Table Depth -----•..................•------••----•--........Rock Size ................................ <br /> Distance to nearest: Wel ...................•...•................Foundation .................... Prop. Line ...................... .b <br /> 1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit -------------------------- Date <br /> Septic Tank (Specify Requirements) ...............' ._ f_.-..,--.. <br /> t.... --yr.................Z..................------------------ <br /> Dis ,�� j <br /> posal field (Specify Requirements) �� 'C '1• �' - ----...... .,�C.fr" <br /> --•---------------------------------------------- -----------------------------•-----•------------•----- ...-•------......-••--•-•••--•--•-_.... ............................................ <br /> •------------.---------------------- ---------------- - __-- ...............-.......................................................................................... <br /> (Draw existing and required addition on reverse side) <br /> 1 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 San Joaquin Local Heald%:Dishict. Nonce owner or llcew <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner <br /> as to become subject Workman's Compensation laws of California." <br /> Signed - -------------------------------- _-- Owner <br /> By ----- -- - ---- Title -------- --------- ---- <br /> (If other than owner) <br /> R PA T USE ONLY <br /> APPLICATION ACCEPTED BY ____ DATE . ".. _._ <br /> BUILDINGPERMIT ISSUED ... -- -------- ---------------------------------....._.._----- ...., .......DATE _.. -- ---------•-----------............ <br /> ADDITIONAL COMMENTS .-- <br /> -------------------- --------------- <br /> . --------------------- <br /> ----- -- ---- -- •... ..........._............. <br /> ---------------- ------------------ .. --.._-.._ . ----- ----------------------------------- <br /> -- _.-.--. --- - - <br /> Final Inspection by: _. -- - - Date . Z. <br /> EH 13 24 Z-bI3 Ifev, 5M SAN .IOAQUiN LOCAL HEALTH DISTRICT 8/7h 3M <br />