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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ..............................,..-•••-•............... Permit No. <br /> lCompletwin TdpNmtQ <br /> ..........I............. . ............................... <br /> ......................................................... This Permit Expires I Year From Date I"Ved Date issued ..12Y <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work heroin <br /> described. This application Is made In compliance with County Ordinance No. 549 and existing Rules and RooWtIonst <br /> JOB ADDRESS/LOCATION <br /> ........ . .........."J...I.......... ...................CENRIS TRACT .......................... <br /> YOwne . 2�f� <br /> r's Name ..........L5I------- ................ . ................................. .. .. V6 7,0<.•-------- <br /> Address <br /> 0 -------- <br /> Address --- ....----1••- .... . A . . .........city <br /> ........................................... <br /> ... ...... . <br /> Contractor's Name .. .............. .....................License# ... Phone Ya::7107------ <br /> ­ ... ........ <br /> Installation will solve: Residence'o Apartment House IJ Commercial OTrallor Court J-_1 <br /> Motel0 Other............................................ <br /> Number of living units:.... .f Number of bedrooms ....Garbage Grinder ............ Lot Size ./.Y-0. .............. <br /> Water Supply: Public System and name ...........................................................................................................Private 0 <br /> Character of soil to a depth of 3 foot. Sand E3 Silt 0 Clay 0 Peat 0 Sandy Loom C3 Cloy Loom Pf <br /> Hardpan 0 Adobe kr Fill Material ............If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system In relation to wells, buildings, aft. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewor Is available within 200 feetJ <br /> PACKAGE TREATMENT f ] SEPTIC TANK f Size!............................................... Liquid Depth .......................... <br /> capacity .................... Type .................... Material:--,.,..._............ No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line...................... <br /> LEACHING LINE No. of Lines --_---_------------- Length of each 'Ibw............................. Total Length ............................ <br /> V Box ............ Type Filter Material ....................Depth Filter Material ............................................ <br /> Distance to nearest, Well ........................ Foundation ................... .... Property Line ........................ <br /> SEEPAGE PIT E j Depth .................... Diameter ................ Number ............................ Rock Filled Yes 0 No 0 <br /> Water Table Depth ................................................Roa Size ................................ <br /> Distance to nearest: Well ................................. Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prov. Sanitation Permit# .................................I......... ..........**.............. <br /> Septic Tank (Specify Requirements) ....... ................. ................ <br /> . ........................... ............. -------- <br /> Disposal Field (Specify Requirements) ... . .....A ...... V................. <br /> ........I...................... ............................ 4E <br /> .......................... ...... <br /> ............. --­-------- ------------------------------------------ .........................­­­4................................................................................................. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that #l�*_work will be done In accordance with Son Joaquin <br /> County Ordinances, Stat* Laws, and Rules and Regulations of fbi"Scit-1 loaciton Local HoaW,District. Nom* w*Mor or Now <br /> sod agents signature codifies the following: <br /> "I codify that in the performance of the work for which IMs p*nvdt Is Issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Compons4th;n laws of Callfomi <br /> Signed ------------- ... ............ .. ........ --- ------- -------------- Ler <br /> BY ------------------ ------ - -- 04.9 Title _ <br /> .... ..... <br /> (if other tha caned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -------------------•-.....•------.....-----------•-•---. DATE171 V1 ....... <br /> BUILDING PERMIT ISSUED ....... ...... <br /> ........ _ <br /> ........ ........*.............. ... ........ ................... ...DATE ........I................................ <br /> �/...... ...... <br /> ADDITIONAL COMMENTS ......... ...... ................................................. <br /> ----------- ................................... ...... .......... ...... ........I.---•-----•--------................_...---......... <br /> ............... ........... <br /> ------ ------------- - ------------ ------------- ------- ----- ...... <br /> ............... <br /> Final I spection by: .................. ..................­................... ................._ -- -----.......... ...Date ... .........__.................. <br /> EH 13 2h 1-68 aev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />