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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..........­........ . ............. <br /> ;7 <br /> Permit Na. .... ...... <br /> [Complete In Triplicate) <br /> .................................... .......... ---- � <br /> ............. This Permit Expires I Year From Date Issued Doti Issued Ze...........7 — <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 Ordinaince No. 549 and existing Rules and Regulaflons- <br /> /CO <br /> JOB ADDRESSAOCA�TfO <br /> S TRACT .......... <br /> ...... ............................._CENSU .... ........ <br /> i. Owner's 'Name. ........M-O-Z- --------- --- <br /> ...........................................Phone fn. 7?.M. ............. <br /> 4' . ........ ........ <br /> Address-._:............... ls� <br /> ........ ................ city _t ................. ............ <br /> . .. . ............1...............1.11cense #2 <br /> Contractor's Name .......... .. ....... ....... Phone -4V...... <br /> Installation will serve. Residence fo Apartment House 0 Commercial oTraller Court <br /> Motel El Other ............I ............. <br /> Grinder ........ Size.` ;2 F0 <br /> Number of living units:_--'.I.,A Number of bedrooms - <br /> 9 Garbage- <br /> Lot size ----- ...................................... <br /> P(Water Supply. Public System;tcf name _--,.....­­­.................... ....................—----- ....................... ..........Private <br /> Character of sail to a depth of 3 feet: SandL3 Sift(] Cloy-0 Peat 0 Sandy Loamy] Clay Loom 0 <br /> Hardpan 0- Adobe[3—Fill Material ............ If yes,type.......... .... ....... <br /> ' <br /> (Plot plan, showing, size of lot, loc6tion"of systern�Jn retdtlon-to,.wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION- (No septic tank or seepage,oli permitted If public sewer is available within 200 feet,( <br /> .t. � 1.) — If <br /> PACKAGE TREATMENT [ I SE'PTIC TANK size------- -------- ........... ...�Uquld'Depth ..15Y............... <br /> Capacity 12-� pe <br /> Ty ..... No.-Compartments Compartments ... <br /> Z, - ................... <br /> Distance to�_nearest: Well -------_57D.....................Foundation .... Prop. Line .5.................logo <br /> .... . .... <br /> LEACHING LINE N6 A& Lines -------.• Length of each line.._ ----7471...._._... To�ta'l Length <br /> V Box <br /> . ........ Type Filter mctie'r'W .---.Depth Filter Material . .. ........................... <br /> 'pt .... ........ <br /> Distance to nearest: Well ..... . ----------- Founda .......... <br /> _V, tion' ........ Property Line ...... ...... <br /> SEEPAGE PIT, Depth .................... &meter ................ Number ---....-------•-- ........ Rock Filled Yes .�No (3 <br /> Water Table Depth ....... ........... ...............Rock Size --- ....... ................. <br /> Distance to nearest: Well ................... .............Foundation <br /> A .-t_� -­-----------_-- Prop. Line ...................... <br /> REPAIR/ADDITIONIPrev. SonitationOermlt# ........__........ ........... ------- --------------- <br /> Septic Tank'(Specify Requirements) _------------- ----------------I....... .................... ...... .....................I........... <br /> Disposal Field (Specify "Requirementsl ................. ------------------ <br /> --------------- ..............................­........................... <br /> -------------­-I— -------------­--i <br /> ---------------------------------------------- --------------------- --------------------------------­....................... <br /> ..............1-1---------------- ------------- ------i------- -------------------------­---I------------I------------------------------ .......................................................I....... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this 'application and that the worki.Willt <br /> . be done Ini'accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of two Son Joaquin Local Health,,District. Home owner or licen- <br /> sed agents signature certifies the following: I I <br /> "I certify that in the performance of the work for which this permit is issued, I shelf not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed1------------- ------- ------- ---------------------------------------------------- Owner <br /> 0 <br /> By ---------- ...Age ------------ ­---------------------------- Title <br /> - --- ----------- <br /> (If.a f than owner) ------------------------------------------------------- <br /> ------------------------------ -- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION-ACCEPTED BY ----- ------_------------- ------•--- ---------------------------- DATE -------- <br /> BUILDINGPERMIT ISSUED -----------------------­--1_;101------------------------------------------------ .......................DATE ........ ------------------­ ---------- <br /> ADDITIONAL COMMENTS -------------------------------------------=----------------••-•..._.............. <br /> ----------------- --------------------I—------------------------------------- <br /> - ----------fl--------------- ------------------------------- <br /> -5 ------------------------------- <br /> ------------- ------------------------------------ <br /> -------------------------- ------------ -------- ....... <br /> ----------------------------------------- ........ <br /> ----­--------------- -----------------I--------------------------------------------------------------------------------- ......... ------- ---- -------------------- <br /> FinalInspection by: --------------------_- ------------------------------------ ..................... <br /> EH 13 8 Ikv. 5m ---- -----------Date �6. - - - <br /> 24 1-6 --_------_------- <br /> SAN JOAQUIN LOCAL HE;�T;JDISTRICT 6/74 3M <br />