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FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT <br /> Permit No. ....... <br /> o <br /> (CompWo in Triplicate) <br /> .......... ........................'...:_.I..---••--•--•- .. 7_r' <br /> Date Issued ..... <br /> ...........v­........ ............. ......... This Permit Expires I Year From Daft Issued <br /> Application is hereby made to the Son Joaquin Local Health'District fora per'mit to construct and install the" work herein <br /> described. This application is mods in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..V ........... <br /> . ..................:.CENSUS TR. .... ..................... <br /> ./.. <br /> Owner's Name --- ....... ........... ................................................................... Phone .................................... <br /> Address ....... ---------------­ <br /> ------ ---- ...I... ...................... city .......... ....... <br /> Contractor's Name �.........................License # <br /> Installation will serve: Residence 0 Apartment House f3 Commercialro Iler Court <br /> P <br /> Motel []Other............................................... <br /> Jlp <br /> Number of living units:-=..... Number of bedrooms ==....Garbc!ge Grinder VXX Lot Size 12-------------_-- <br /> Water Supply:-Public System and name .•--------•-•....... ................... ............. ..............................................Private <br /> Character of soil to a depth of 3 feet. Sand 0 Slit Q Clay 0 Peat JJ Sandy Loom{:j Clay Loom 0 <br /> Hardpan 0 Adobe Fill Material ............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 feet4-< <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size........................ .............. ......... Liquid Depth ---------_-_---- <br /> Capacity.----- ............. Type .................... No. Compartments ...................... <br /> Distance. to nearest. Well _.................................Foundation ---__---.___ Prop. Line............... . <br /> LEACHING LINE No. of Lines ---------------4-------- Length of each line..-- . ~ . Total Length ..,....... .......... <br /> 'D' Box ....... ter ...P#pth Fllter'Mctteriol� ........._--------_---- Zz <br /> ,',Type Filter Material ................. ............. <br /> Distant to'nearest, Well ................... .... Foundation ......................... Property Line ..................... <br /> -SEEPAGE PIT Depth ------: ......... Diameter ................. Number ................... ...... Rock Filled Yes No 0 <br /> Water Table Depth ... ......... ............... ..................Rock ......................... <br /> , L. le - .. . Prop. Line ...... <br /> Distance' tonearest: Well -----I..'.'_':�...........................Foundation ------ .. ....... ... <br /> REPAIR/ADDITION(Prev. Sanitation!Permit# ............::.............•......_•..__..._.. Date------:__............_...__-.___..I <br /> Septic Tank (Specify Requireriftnts ..... <br /> Zlete_- <br /> eiiients) ............................................ -­---------------- 2...... <br /> Disposal Field (Specify Requir <br /> -------------------------------------------------------------------------------------------------------------------- ................................. ............................ <br /> ---------­-------I—--------------- -------------- --------------------------------- <br /> (Draw existing and required ciddition on reverse side] x <br /> I hereby certify that I have prepared this application and that the work will be done In accordance. with Son Joaquin <br /> aquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heallk District. Home owner or licen• <br /> sod agents signature certifies the following: <br /> "I certify that in the Performance of the work for which this permit Is lisued, 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 ----------- <br /> ............................................ litle ...... ......... _---_---_---- <br /> other an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION -ACCEPTED BY ------------------------------------------------- <br /> ------------------ <br /> _--------------------------- <br /> BUILDING PERMIT ISSUED ------------ ---------------- ............................................................. .........DATE <br /> I <br /> ADDITIONAL COMMENTS --------------__---------------------------------------------- .......................................... ....... ...... ........................ <br /> --------------------------------------------- --------------- ........ ............... ................... --------- ­------------­----T..........I......... <br /> .................... ........................................... ................. ........ ...........................................................­11................................ ........ <br /> ------------ ................ ...... .............. ...... <br /> AO,�v J _-------------- <br /> . <br /> Final Inspection ...... .... . . ate .. <br /> -------------- <br /> ]EH 13 24 1-68 Rev- SAN JOAQUIN LOCAL HE t UMI 8/7h 3M <br />