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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />.............................. ....... Permit No. ....7...3 <br /> ...... ... <br /> ... . <br /> (Complete in Triplicate) <br />............................................. . ..... Dote Issued ...1................ <br /> ........... This Permit Expires I Year From bate Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a per"mit to construct and install the work herein <br /> described. This application is made in compliance withCounty Ordinance No. 549 and existing Rules and Regulations: <br /> ------ <br /> ... ............:........_......CENSUS CENS US TRACT ............... ....... <br /> .OB ADDRESS/LOCATION .....� .) <br /> Owner's Name .... .. . . ........ ------ ._......I.-••....... .. .......Phone ...... <br /> Address ....... ...... .......... ...................... City ... ........................................ . <br /> Contractor's Name - ---- ..... ..... ---- - -- �Aicense #aJ;.Z17.7.. Phone / <br /> J <br /> . ..9 <br /> Installation will serve; Residence fXApartment House 0 Commercial ]—]Trailer Court 0 <br /> Motel F1 Other -----------_--------- -----_------------- <br /> ooms t Size ...... <br /> 10- Lo <br /> Number of living units ...../--- Number of be ....Garbage Grind r <br /> �_a ❑ <br /> Water Supply. Public System and name .......;Or*;:�at---------eve. _ . ........................ .......................Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt[J Clay [:] Peat 0 Sandy Loam Clay Loam [3 <br /> Hardpan 0 Adobe iW Fill Material .........— if yes, type --_--------------_------- <br /> 01Z <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK '5:Xl i.ze...........•............................. ....... Liquid Depth .......................... <br /> Capacity 3!j11111111 1-1�. iype -------------- Material...................... No. Compartments �........—.......... <br /> Distance to nearest: Well ------------------------------------Foundation .... -_-------------- Prop. Line ...................... <br /> uJ <br /> LEACHING LINE No. of Lines _.___._.-e<__....._. Length of each line.._.__ ........... Total Length ............ <br /> V Box .. Type Filter Material Filter Material .--,`.9----------------,•-•-••-_-••__._ <br /> Distance to nearest- Well -Foundation 4............ Property Line ��................ <br /> SEEPAGE PIT Depth ----- Diameter Number ......... ........... Rock Filled Yes � No 0 <br /> • ....... ...—---Rock Size ..... ........... <br /> Water Table Depth ... ..............­­ ; .11, 1 <br /> Distance to nearest. Well ...xo___��A ---------Foundation ........ Prop. Line 2�................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ....--------•---- •- -----• ........ Date ................................••I <br /> P <br /> Septic Tank (Specify Requirements) --------------_ .. .... .......... ......... .. ... -----...••--•.....-......... .............---------------_- --- <br /> ... ...... - --- ------ <br /> Disposal Field (Specify Requirements) . <br /> ..............-................................... ---------- <br /> ------------­--------—---------------------­-------------------- <br /> .............. _------------- <br /> ....................—..........................I-------------------------------------------------....................... .......................................... <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 <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: permit is issued, I shall not employ any person in such manner <br /> "I certify that in the performance of the work for which this pe <br /> as to become subject to Workman's Compensation laws of California." <br /> I,." _,Signed ...... ----------------- ..... .............. . .............................. OwneA..,.�. . <br /> ........... .......... Title 4 .......... .......... <br /> BY --- <br /> (if other than 6wheri <br /> FOR DEPARTMENT USE ONLY A <br /> APPLICATION ACCEPTED BY . ...... DATE .... .... <br /> ----* . ............... ..............*-------------------- ------------ .......* R <br /> BUILDINGPERMIT ISSUED .--- -- ------­------------------I...................1--­.............—........... ..........DATE ....................... ............. <br /> ADDITIONALCOMMENTS ............................................................ ......................................................................... ......................... <br /> .............................. ..............I................ .......r�........................................... .... _­......------.------I.......... <br /> ...............................r.......................................... ..................... .........- ............ ............................•...... ... .................................4.. <br /> .............I.----------------------------- .......I--- <br /> V. ... ........ .................. <br /> ............ ---------­_ .-Date ...1� <br /> Final Inspection b ................ .................... ...... ................................. <br /> y .......... <br /> SAN,JOAQUIN LOCAL HEALTH DISTRICT <br /> 7/72 3 M <br />