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r UF110E USE: <br /> ............­........__-.1......... ........ APPLICATION FOR SANITATION PERMIT <br /> . ._.._..__I....__..--•... ........ ...................... 4- lComplefe in Triplicate) Permit No. ..................... <br /> .........I.......... ............... ................. This Permit Expires i your From Date f saved Date Issued 7& <br /> Application is hereby made to the Son Joaquin local Health District forN <br /> a permit to construct ad Insthe work <br /> described. This application Is made in compl lance )Xith County Ordinance o. 549 and existingnRulestaanlld Regulations,herein <br /> JOB ADDRESS/LOCATION <br /> ....... ... <br /> .........._...CENtUIS TRACT .......... <br /> kr <br /> Owner*s Name ........ <br /> .............. <br /> 'Phone �� <br /> .,7 9 <br /> ...... ... <br /> Address _17_149� <br /> - ----------------------------- ------- ---------_ -------- <br /> Contractor's Name -------------- ........... <br /> ------ ------------------ --- ---- ----------- .......!.License # ...... <br /> ............ Phone ------ ------- <br /> I Installation will serve: Reslclencet6��artment House Ot6mmercial OTraller Court 0 <br /> Motel [I Other ------------- ti <br /> - <br /> Number of living units:__ ---- Number of bediooms-,=.?_ ;...Garb) i <br /> . age Grinder ............ <br /> Lot Size -------_--&&S4 <br /> Z,.Z............ <br /> Water Supply: Public System-and- <br /> ------- ...... .. ... <br /> Character of soil to a depth of 3 .. Private fzl-- <br /> feet: ❑Sand E] Silt[] Clay 0 peat jSandy Loam 0 Clay Locim 0 <br /> Hardpan 0 Ado-boo. FilIM6terial ......... <br /> If yes, type ............... ............. <br /> (Plot Plan, showing size of lot, Ic6tion of system in relation'to Wells; buildings, etc. must be placed <br /> NEW INSTALLATION: (No septic on reverse side.) <br /> tank or seepage pit permitted If public sewer is available within 200 feet) <br /> PACKAGE TREATMENT-J SEPTIC.TANK f <br /> Size-----------------------------------------------. Liquid Depth .... ............ <br /> Capacity <br /> I........................Type�.....................Waterial---------------------- No. Compartments ......... <br /> Distance to nearest: <br /> re�st. Well ....... ................... -------Foundation -----------_--------- Prop. Line ..................V <br /> i I ' r <br /> LEACHING LINE ( IJ Nd. oULirJes _r--------I-------- Length of each line.-----------•--------- ...... Total Length ...........................J P <br /> D' Box. ..".__..._ Type Filter Material ............ i <br /> L I I ...... Depth Filter Material <br /> Distance to nearest: Well .... ......:�.' ; i <br /> ------- ........ Foundation -------------- ......... Property Line ........................ <br /> SEEPAGE PIT Depth .......------------------Diameter .................. Number <br /> I ........................*--- Rock Filled Yes 0 No 0. <br /> Water Table Depth ..................r..............................Rock Size -•--------•--------------------- � <br /> Distance <br /> ------------------ <br /> Distance to I nearest. Well ................••._•.--•-----_ Foundation .......... ......... prop. Line ...................... <br /> REPAIR/ADDITION{Prev. Sanitation' <br /> Permit# .............­­............... ..... Date <br /> Septic Tank JSpecify Requirements) <br /> ................ .............. ........... ...... .......... <br /> D's asaI Field (Specify Requirements) <br /> 4 - ---- -•----- - --- - - <br /> �7 . ...... -----------­- -------- ........... ......I . <br /> -- ------- ..... <br /> -----------------------7-------------------------------------------------_.................................. <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: <br /> "I certify that in the performance of;the work for"whichthis permit Is issued, I shall not employ any person In such mcimier <br /> as to becom subject 0 Workman, Comp#'ItiOn law of California.— <br /> Signed --- <br /> .gned ----------------••------------- wrier <br /> By ..................... ------ <br /> "m subject o Workman' <br /> ------- ----------- <br /> (if other than-ownerl'­. -------------------------------------------- Title --------- ------- ------ -------------------------- ----------------- <br /> R IDIEPARTMLWT-USE ONLY <br /> APPLICATION ACCEPTED BY .- <br /> Dl <br /> MC <br /> jj..� <br /> ISSUED <br /> � ......DATE q�77� <br /> BUILDING PERMIT ISSUED ............ --------------- <br /> . ..... ...... ............. . <br /> ADDITIONAL ------------ ------------- --------- <br /> .............. <br /> COMMENTS ....... ......----`----•-.-- ------ -------------------------------------DATE ........................... <br />. ..... ..... ......................4--------------- ------------------------------------------ <br /> --------_----------------I-------------------- ...............I-------­----------------------- ------ -----­---- ---------------- ................ ...................... <br /> ­-­---------- ---- ---------- <br /> ........ ................... <br /> -------------------------------------------------- <br /> -------------*----------------- ------ ---------- <br /> ......... ------ -------_-------__........Date .......... <br /> EH 13 2h 1-68 ------ ...... <br /> Rev. 5K <br /> .............. --------- <br /> Final Inspection by: ......... ;Y 1--i-- ----- -------- ........ <br /> SAN JO QUIN LOCAL HEALTH DISTRICT 8/74 3m <br />