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�wfr v <br /> ....... ......... ........._........ ..... APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No, <br /> ............... ...... ....... <br />........................... .......... Date Issued <br /> • <br /> This Permit Expires 1 Year IF rom Date Issued . .. . <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct afid install the work herein <br /> described. This application is made in compliance with County Ordinance No, 549 and existing'7Rules and Regulations. <br /> JOB ADDRESS/LOCATION ..../05� <br /> .............CENSUS TRACT ....... <br /> Owner's Nome� Z <br /> ....... ...... ...... ........Phone .......... <br /> R4 <br /> Address <br /> .......................I City 56" <br /> AZ em A0 7: <br /> Contractor's Name License # <br /> ------------------ ................ Phone <br /> Installation will serve: Resiclenscg�x_ Apartment-House 0 Commercial ❑oTrailer Court 0 <br /> Aeotel'❑Other _...:.:..I.....................__....... ? <br /> Number of living units0'�_/- <br /> . .'.__ Number of.bedrooms ...........Garbage Grinder ItIr- Lot Size <br /> ........... <br /> Water Supply: Public'System and name .....................? <br /> ................... <br /> Character --------------------------------------- <br /> ..............PrivateX <br /> of soil to of 3 feet, SandE3-1-Silto Clay 0 '�_Peait <br /> Sandy Loam 0 ,. Clay Loam n <br /> Hordpang Adobe C] Fill Material If yes,type '__________________ <br /> (Plot plan, showing"-size of lot, location of system.-in relation to wells, buildings, etc, <br /> must-be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit--permittedL if public,sewer is available' ailable within 200 feet,], , <br /> PACKAGE TREATMENT SEPTIC TANK Sia®.,.....---------- 1---------------I............... Liquid Depth ......... ................ <br /> Capacity -- --------- Type .............I Material -----------I......... No. Compartments .................... <br /> Distance to.-nearest:1 Well --------_- ..............Foundation................� ...... Prop. Line ...................... <br /> LEACHING LINE No. of Lines ------_-------------_--Length of each line...._____... ....... Total Length ............................ <br /> 7V Box ----_----- Type Filter.Material ........... Depth Filter Material ........................ ................... <br /> Distance to nearest- Well ----------- ----_---_ Foundation ........._._....7...._.. Property Line ........ <br /> SEEPAGE PIT Depth .......I_---_----- Diameter........ <br /> ... Number .......-.'Rock Filled Yes ❑ No ❑ <br /> Water Table Depth .....Rock Size ................... <br /> Distance to nearest: Well -----------------------------------------Foun-dotion ....... ........... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .........................._ % <br /> .. ........... Date ........................... <br /> Septic Tank (Specify Requirements) ----- ............. .V....................... <br /> Z <br /> ... ....... ....... ............. -------- <br /> .... .... <br /> Disposal Field (Specify Requirements] �Ja <br /> ................... .........-........................ <br /> --------------------------------------------------------------------------------------- <br /> ---------------------------------I..................................I---------------I.............................1-......... ... .............­­............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 lic*n. <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 manna <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ........ ---- ------------ <br /> - ----- ---I....... ........ ........................I.... Owner <br /> By ................ . _ _ ­..-.7itle Y. iuorlp?._ "..r........... <br /> ?V,1-1 Y. <br /> e� <br /> other t an owner) <br /> FOR DEPARTMENT USE ONLY <br /> AP PLICATION ACCEPTED BY ....................• ----------- <br /> DATE . /49/`­­!- �/"`Z`X"` <br /> BUILDING PERMIT ISSUED .......... ....... <br /> .......................... .........................................DATE ._..-•-----:...................- <br /> ,ADDITIONAL COMMENTS <br /> ................ .................... ....................... ....... ........... ........... ............... ...............I.........I........... ....... ......................I......... <br /> ........... ------------- ......... <br /> ............... ......... ............ ..............•-----•--.I.....__..__ ...... <br /> ............. ............................... ....................................... ........... ............................. .. ...................... <br /> .0i <br /> -1_�7 -- ------ <br /> Final Inspection by: ..................... . ........... .. ------- ........... <br /> ....Date ........ ....... <br /> SAN JOAQUIN -LOCAL' HEALTHDISTRICT <br /> F w 13 24 i_-Aa D_ rill <br />