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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ......... ---------------41�............. <br /> -- .............. (Complete in Triplicate) Permit No..................-. <br /> ..............__.------- . . <br /> Date Issue - <br /> .......................... ........................... This Permit Expires I Year From Doto Issued ...... ........ <br /> Application is hereby mode to the Son Joaquin Local Health District for a permit to constru'cro' ncl Install the work herein <br /> described. This application is mode in compliance with County Ordinance No 549 and existing Rules and Regulations: <br /> 17 <br /> Z <br /> JOB ADDRESS/LOCATI N . .... .......CENSUS TRACT .......................... <br /> Owner's Name .......... ................. hone <br /> . ... .. ........ .. <br /> Address city <br /> .............. <br /> ................L I c e n s e # Z 71.. Phone a n e <br /> Contractor's Name -._ <br /> Installation will serve: Residence M14a ment House] Commercial OTrallor Court 0 <br /> Motel El Other ........................................•--- <br /> Number of living units:............ Number of-bedr m ......Garbo Grinder ............ Lot Size ....................................... ...... <br /> Water Supply: Public System and name ?m 7AO'"/ ..% Private Q1 <br /> --- -------— a-Z. <br /> .. .........................................................._._..........._.................Private***...... <br /> Character of soil to a depth of 3 feet. Sand 0 Silt 0 Clay 0 Peat 0 Sandy Loom 0 Clay Loom 0 <br /> J <br /> Hardpan C] Adobe 0 Fill Material ............ If yes,type ............... ............ <br /> 1plot 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 3 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 line............................. Total Length ................... <br /> 'D' Box ............ Type Filter Material ......._...Depth Filter Material .............. <br /> Distance to nearest: Well ........................ Foundation ......................... Property Line ........................ <br /> SEEPAGE PIT Depth .... ------------_- Diameter _--•--.-_.:..... Number ............................ Rock Filled Yes ❑ No (:1 <br /> Water Table Depth ......... ...... _--------Rock Size ................................ <br /> Distance to nearest: Well ---------_ ----------------------Foundation _................. Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ­....,........... ----------------- Date ------••------..._.-.--..._.......} <br /> Septic Tank (Specify Requirements) --------------- ------- --- -- -----_---------------- ......I-----------;........................................................ <br /> Disposal Field (Specify Requirements) -------- ......... <br /> --.................................................... <br /> ------------------ --------------------- -------­----------- ----------------------------------------------------------- ---------- .................... ....... <br /> -------------------------------- -------------------------------------------------------------- -----•-----------•----•------------------------ ........................... ................. <br /> (13row 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 Ilcon- <br /> sed agents signature certifies the following: <br /> "I certify that In the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------------------------- Owner <br /> By ------------------------------------- title ........ <br /> FOR DEPXkTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------- ..................... DATE �_......... <br /> Z <br /> BUILDINGPERMIT ISSUED _.............. ........ -----------------___------------------- ------ _----------------_:---_-DATE ............... --------- ............. <br /> ADDITIONAL COMMENTS ----- -•------------------------ ell 1-1 <br /> -----------I.......I---------------------------111--------I------------I——--------- -------------------I------"I------------------------------ ............. <br /> •----- -------------- -- -------------------- ...........I------- -----------------------­--------__-------------------------:------------------------------- -------I--------- -- <br /> ---­------------- . .... ............ <br /> Final Inspection by: .---- <br /> ....... .................................... .........Date .....................1­_-.�................ <br /> EH 13 24 1-68 Rev. 5m <br /> or4,, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3-M <br />