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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .............. ......................................... <br /> Permit No. .7r <br /> (complete In Triplicate) <br /> .............. ...................r.............. <br /> Date issued . <br /> ........... ................. ........... This Permit Expires I Year-Frorn Date issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to constrict and Install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> .------- ......... . <br /> r4n k <br /> S .JOB ADDRESS/LOCAT ......... <br /> ..............................CENSUS TRACT ......... ................ <br /> Owner's Name fs . ............. ....... _ ..Phone <br /> ............... .................... <br /> Address ------- <br /> ----------- <br /> .. . . .....I............ city....".... ...................­­....................... <br /> 11 <br /> Contractor's Name --- ...... ......... ------------------------------License Phone <br /> Installation will serve.. Residence U4rportment House 0 Commercial Oftiffi­r Court jj <br /> Mote'] 6 Other'............................................. <br /> Number,of living units ie—Number of bedrooms ............Garbage Grinder ............ Lot Size ..... ....e .. _:•=__--......... .................. <br /> Water Supply. Public System and name -,------_----------------------------------------------....................................................Private Er_� <br /> Character of soil toa depth of 3fe6t. SandO Silt Cloy 0 Sandy Loom 0 Cloy Loom 0 <br /> .Hardpan[J Adobe��Moteriol ............ If yes,type............... ........ <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,l <br /> PACKAGE TREATMENT f ] SEPTIC TANK[ Size.............. ........ ......................... Liquid Depth .................... <br /> Capacity --------------------- Type ............. Material---------------.....-. No.' Compartments .................. <br /> Distance.to nearest. Well _....__._Foundation ...................... Prop. Line ......................0 <br /> LEACHING LINE No. of Lines ------------------------ Length of each line............................ Total Length ............................. <br /> V Box ------------ Type Filter Material ....................Depth Filter Material ............................................ <br /> Distance to nearest: Well ........................ Foundation -------- ............... Property Line ......................... <br /> SEEPAGE PIT Depth ------•............. Diameter ---_---------- Number ..................... Rock Filled Yes [3 No 0 <br /> WaterTable.:Depth .................................................Rock Size ................................ <br /> O <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line .--_---....._.........'1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date .............................. <br /> Septic Tank (Specify Requirements} ------- ...... ............. ............... ---------­- .................... ....... ...................... <br /> 4�,_- -, <br /> . .. .............. ....... .... <br /> ...... ......... <br /> Dispoial Field ISpecify Requirements) ------------aw____-__-_• ....... <br /> -------------------­ J <br /> ------------------------------------------------------------------------------------------------------ <br /> -----­----------- ....... -----------------­­- ------------------------ ----------------­-----------.......................­­............................................................... <br /> (Draw existing and requited 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 /> "[ certify that in the performance of the work for'which this permit is Issued', I shall trot employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---------- - ------------------------------------------------------ .................... Owner <br /> By ---- --- ------- - ----- - -- - - -------------------------------- ... ................... <br /> ...........- Title -------- ------- <br /> other than owne' r)" <br /> FOR,DEP 4RTMENT USE ONLY <br /> APPLICATION ACCEPTED ,BY -- ---------- --_ --------- ----------- ----------_---------DATE <br /> BUILDINGPERMIT ISSUED ------------------------------------------- .................... -----------------_---_..............DATE ....... ........ ...... ---------- <br /> ADDITIONAL COMMENTS _.----------_--------- ....... <br /> 0c <br /> -­-----­-- ------------- -- -- _- _- - <br /> -------------­-- •­:­4-------------­.................... .......... ... <br /> ----------------- X­ ....... ----------------------------------------------------------------- <br /> --------------- ---------- -------_------- ------------------------------- . .... <br /> oo <br /> . ................ <br /> Final Inspection by: ----- ------------------------- ....................... <br /> EH 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M <br />