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FOR"OFFICE USE: FOR OFFICE USE: <br />APPLICATION FOR SANITATION PERMIT <br />(Complete in Triplicate) Permit No­7?.-J-'�/ <br />Permit <br />--- <br />\t .Date Issued --r- <br />..................... ...... 7.7 <br />.......... This Permit Expires I Year From Issue;d <br />Application is hereby made to <br />the Son Joaquin Local Health District for a permit;to -construct and install the work herein d4s&ibed. <br />This applicatio'n is made in compliance with County Ordinance No. 549 and existing, Rules and Regulations: <br />g <br />JOB ADDRESS/ LOCATION <br />.. ........ <br />................. <br />........... ..CENSUS TRACT ....... <br />Owner's Name.,.. ...... <br />............. ........ Phone <br />Addr <br />s ............. <br />ss <br />s <br />C tra ors '---- -3, -...Phone... ......... ...... .... . License # - — P <br />Installation will: serve: 'Residence Apartment House E) <br />Commercial El -Trailer Court E) <br />Motel EJ; Other ,- ..... :: .................... <br />Number of living' units, -.-"'4 ..... . Nurnh�erof bedrooms ... _...Garbage Grinder...,...._ Lot Size -__T .. .......... <br />Water Supply:" Public System an' name---:.-:: -:: --- <br />----------- ------ <br />.......... -- --­---------- ------­---- Private L <br />" --- <br />Character of soil to a depth 0filieet: Sand EJ Silt❑ 'ClaybPeat E]•Sandy Loam Clay Loam <br />Hardpan E] iAcloSe[] Fill Maieriall ......__if yes, type.- -. ----------- <br />.. .......... <br />k— 'I <br />(P18t plan, showing size of 16t, 16catibn'of system in relation to wells, buildings,*etc. must be placed on reverse side.) <br />NEW INSTALLATION: (No- septic--tan-k or seepage pit permitted if publit sewer is avci`iTablevaithin 200 feet,) <br />PACKAGE TREATMENT S&TICTANK Size. I <br />-"Liquid Depth ... <br />iCapad Type- .......... Mfateri'al ....... No. Compartments-,.. <br />ff <br />Distan <br />c 'to nearest:.Well ........ ...... - ------------ ;Foundation- ....------.Prop. Line ...... t�- <br />LEACHI' G LINE N No. of [Iines.'�. ----------- ;Leng*th of each­line��t'�." ............ 1-TotaI..Leng4-,--/-7,P­­-, ....... ...... <br />'D' Bo,1j'­ .`.. !Type Filter Mciterial­-/ <br />Depth Filter Material <br />Distancl to nearest: Well.;./_ 0 . _e., <br />I � ... ...% .­-,­.e� —Foundation ------------- ..........._..Property Line..: ......................... ...... <br />bept iter.�:k3fxl".N * umber ... - ------ 4c42-%- : 11 . Rock Filled Ye No El <br />.411 <br />Water Table Depif�-,, J, <br />............. .......... Rock Size..... <br />Distanc tb hdarE;it� 6,11 0P LiWe­tC. <br />REPAIR/ADDITION (Prev, Sonitation;Permit #­ <br />.-- . ...... ...... ------------------- Date.- . ­:,.­ ---------- - <br />, ------ <br />Septic Tank (Specify Requirements) .-..-t .... J_-._:•__:_....._-:_;._. ,, <br />. .......................... .............. ............. ------­----- - -------- <br />--- ---- - ------------ ­ ------- <br />Dis ( posal Field,(Specify•Requirements)-] <br />. . ..... <br />............ ........... --------------------- --------------------- --­-------------- ....... I., ................ <br />................... ......... ... ........... <br />----------- ......................... �rw ....................... .......... .... .................... ---------­------ ...... ..................... . . <br />----­-------- --------------------------------- <br />.............. ......................... ---- ------------------- ..................... <br />............. <br />li <br />(Draw existing-orid required addition on reverse side) <br />I hereby certify that I have prepared his'applic-a- tion 16'rid that the work will be done An accordance with San Joaquin County <br />Ordinances, State Laws., and ules and ltegClation)s of the Son Joaquin Local Health District.. Home owner or licensed agents <br />signature certifies the following: <br />"I certify that in the performance 'cif thew`ork for: which this perriiit is issued, I shall*no z t- <br />employ any person in such manner as <br />to becorne subject to Workman's Compensation lc;�V-SCof California.".IR 1! <br />Signed •. ... ... ........................ . <br />F A <br />......... <br />-------- <br />- ...Owner <br />Ti ei ......................... <br />By.... - --------- <br />If other Than ow er <br />1OP. DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY. <br />DIVISION OF LAND NUMBER. <br />ADDITIONAL COMMENTS. <br />...................... ------------------- <br />........................................ <br />Final Inspectiori by:.... <br />EN 13 24 <br />.... .. ......... -------------------- ............................................... <br />DATE. - ----- <br />.. .. . ...... <br />- - - - - - ---- - - - - - - --------- DATE ------------ .............. <br />........................... ................ ................... ...... ...... .......... . ................. . <br />­n,c ------------ 4 <br />, ri . k ,e <br />.......... ......... : .......... : ............... <br />...... ................ ---------------------------------- -------- <br />-------------------------- ------------------ ...................................... ­ ............. ............. <br />........................................-------------------- ............. -- ----------- --- <br />------- -Date .... 1- .1-.!0 ;;�� . ..... ­ ............ <br />..................... ............................................ <br />SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />