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FOR OFFICE"USE; FOR OFFICCUSE'-- <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------\ ........ .... .. ........ lComplete in Triplicate) Permit N07f <br /> ................. <br /> Date Issued......:77�1717f <br /> .......•--------- - -- ------ _---------- This-Permit Eipires, 1 Year From Dist* Issued <br /> ......... <br /> Application is hereby made to-the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC10N. ....... .... . ....... ...................CENSUS TRACT...--..-.. ' <br /> Owner's N <br /> ...............:......Phone.............-.-_.._.........---. ...... <br /> ..-(................... <br /> Address............ .......... ......... ........__.......-Zip................. <br /> 07r- ... . .... ....................... ...... .........City..................I <br /> Contractor's Name.......oe . ....................... ....License #001" Phonef._IM4 . .. ...... <br /> Installation will serve: Residence J1 Apartment House E] Commercial ❑ Trailer Court E] <br /> tel F-1 Other. _........... _---------------------- <br /> Number of living units:....-. ......Number of bedrooms---.... ...Garbage Grindew....:.......Lot Size---- ........ <br /> Water Supply; Public Sys, and name---------------- ............. ...... ................ ......... ...... ...........Private <br /> ❑ <br /> Character of soil to a depth of 3 feet; Sand ❑ Silt ❑ Clay Peat ❑ Sandy Loom C] Clay Loom E] <br /> Hardpan F­] Adobe ❑ Fill Material.. .,.If yes, type........7......4................. <br /> (Plot plan, showing size of lot, location of;sys'tem in relation to wells, building's;etc. must be 'Placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or.,seepage pit permitted if public sewer-is ovailable.within 200 feet,) GK' <br /> PACKAGE TREATMENTSEPTICTAN.K-1 1, Size........ .................................... ­­-------Liquid Depth.....'--- ....... <br /> Capacity....-- .. .... -----•-Type............. � erp .............. ...No. Compartments......... ... <br /> Distance to n6brest:,Well___ ...-Foundation........ . . ...... ...!_Prop, Line-.-. <br /> .......... <br /> Pe. <br /> LEACHING LINE , No. of Lines....... ---­---------------Length each lina.........._,_.............Total Length .............__.......... <br /> 'D' Sox----........Type Filter Material Depth Filter Material.....-----"................................ <br /> Distance to nearest; Well-e, -foundation..............................Property Line..................--.............. <br /> SEEPAGE PIT Depth .. ............Diameter--/--'.-....:--.Number...__...... ........... 'Rock Filled Ye Noo <br /> Water Table Depth..............................._­.......................Rock Size..... ......... <br /> Distance to nearest: Well------------------- *------Foundation..,....... .• <br /> ......... ro'p. Line............. ...... <br /> li <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------- ........... ...............Date . ................................ <br /> Septic Tank (Specify Requirementsl...... ........ ........................................... <br /> .......... P ................. ......... ...... ................ <br /> Disposal Field (Specify Requirements). <br /> -­------------------------­ 0 . ..... .... ................ <br /> ----------------- -- ------ ........... ----------------- --- ---- -------- ............................ ..... ......................-.1............ .......... <br /> (Draw 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 County <br /> Ordinances, State Laws, and Rules and R. gulations of the Son Joaq"in,Local Heal th.,.Di strict.-H a me owner.or.licensed-agents, <br /> signature certifies the following: <br /> "I certify that in the performance of the 'Work for which ti�i, pe�mit is'issued, ! shall not employ any person in such manner as <br /> to become subject to Workman's Co 4 ation laws� of' CaliforInia.""', <br /> 7 <br /> Signed.----- .. ...... ... ...- ..... ......... . .... .. --------- ----------- Owner <br /> By-•---------- ..... . .. ........ .......... ............ .............. _------------------------ - <br /> I 17t - i <br /> f ot� r t a n o Tne 0 <br /> 7 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYYA--- 'V4---—--------- ------- .......................­........... ...---...-'---....... ........DATE ....... <br /> DIVISION OF LAND NUMB EZ.-)............ ............................... ............................................... ......_DATE...... ........... <br /> ADDITIONAL COMMENTS.......--. ........... ........................................... ----------------------------------------------- ......... .............. <br /> ---------- ...... ...... ....................... .................. ....................... ------ ........ ............... .......... ............ ........... ..­­............ <br /> ..................................... ...... .... . ... .;- ------------------- ...................1­----------------------------------------- .......................................... ..........--- ••-- ......... ------- <br /> Final Insp6ct1on b - - --------- -------------I------------- ... ...... -------------- ---------- -------- --- ---------- <br /> .y ... ... . .. ... . ... . ...................... -- <br /> ------- ......... ----- -------------- ............Date.-.-- <br /> ... ............... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />