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'FOR OFFICE USET0V____ <br /> APPLICATION FOR, SANITATION PERMIT <br /> ............................. ........ ........ <br /> .............. Permit No, 7s­- s-�/- <br /> ...................................... .... (Complet"In Triplicate) ............. <br /> ............. .............. ........ <br /> ......... .................. This Permit Expires Year From Date IssU*d Doti Issued ...... <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct an <br /> described. This application is made in corn ;��Instoll the work herein <br /> compliance with Coui) y Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION <br /> _a"r.. CENSUS TRACT <br /> Owner's Name <br /> . .. ........... ............... <br /> .. ....Phone ....... <br /> Address ............ ............................... <br /> ... ... ............... City <br /> . ...... .. <br /> .......... .. <br /> Contractor's Name .._-- ........... <br /> ... . ......... __...license # <br /> one <br /> Installation will serve: Residence Apartment House lb Commercial oTrall&r Court <br /> Motel [3 Other.... <br /> Number of living units------------- Number of bedrooms ... - 1� - - - - <br /> Grinder ........ Lot Size' <br /> Water Supply. Public System and name ....... ............................1: <br /> Private <br /> Character of soil to a depth of 3 feet: Sand E] Slit 0 Clay 0 Peat 0 Sandy Loom 0 Clay Loa <br /> + <br /> Hardpan 0 Adobe [] Fill M6terjol ............ If yes,type............... ........... <br /> 0 <br /> (Plot plan, showing size of lot, location of system in relation'!i to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION. (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f I SEPTIC TANK size,'...LI.-A-67.4-4.6............. Liquid Depth <br /> pth .4,.... . <br /> ...A-P.0yp.e ..................L Material . ...... No. Compartments <br /> ©'stance. to nearest: Well .04................Foundation ......./-0....... Prop, Line ....I................. <br /> LEACHING LINE f j No. of Lines ................ Length of' each line­­-AqA"........ ... Total..Length ... <br /> 'D' Box . il <br /> e0--,P1'7 Type Filter Material 15�...Depth -Filter Material .. <br /> rest: Well .... ........ Foundation ........ Property Line ....... <br /> Distance to nea,I ? e . <br /> SEEPAGE PIT Depth ....... Diameter Number ........ Rock Filled Yes 'O No <br /> 11 1..�3...I........... <br /> Water Table Depth -.--__._.•........................ ..............Rock Size ........... ........ <br /> Distance to nearest. Well .......................I ..............Foundation ....... <br /> .......... Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .....................I......... ............ Date ............ <br /> ................. <br /> Septic Tank (Specify Requirements)._.-:..•........._ <br /> Disposal Field (Specify Requirements) .............. ................. -------- <br /> ------------------------I-------------------------­ --------­---I——................ .................. ...................................... .......­ .......... <br /> ­--------------------- ----------- <br /> .............I.........­­............................... .......... <br /> .................. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and th ail the work will be done In accordance with Son Joaquln <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local H9a1&DjSfyICt.r.IR0M* owner or licen- <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 /> Signed .... <br /> ---------- ...... ..... . .­...... Owner <br /> By -------------------------...... .......... Title ..................... <br /> ---- ---- --- <br /> lif other than owner <br /> FOR DEPARTMENY USE ONLY <br /> APPLICATION ACCEPTED BY -------------------- ------- . ........ DATE <br /> BUILDING PERMIT ISSUED .--_/ - ------- ------ - . . .... ............. ........................... <br /> - -4DATE ....... <br /> .1, . . ..........I——.......____------I................... <br /> ADDITIONAL COMMENTS . ..... <br /> ..............----------"•----.-...---------------------------------:--)..........­...... <br /> ........... .........I............j----------- ------ -------_--------------------- - ---------- .................................. ----------­............ --------- <br /> ----------------­............... ...................... .................. <br /> ---------_-----............... ----------------1­---------------------------- ........................... ......................T.... <br /> Final Inspection by: .........._ -cP I�_-4--- ­------- <br /> ...... ........ ................ Date ...... <br /> EH 13 2b 1-68 Rev. 5� --------------- ......................... <br /> .. .........­-------- <br /> SAN JOAQUIN LOCAL ;HEALTH DISTRICT 8/7h 3M <br />