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FOR OFFICE USE- <br /> ......... ................... ...........­....... APPLICATIONI FOR SANITATION PERMIT <br /> (COMPleteinTriplicatePermit No. <br /> ........I...........I............... ...................... . ll., ................ . <br /> ...... ................ ..............­.......... Date Issued . J 7;7 <br /> This Permit Expires I Yoor'Frorn Date Issued ............... <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _475#...... jll�� 41- .................. <br /> -97441L ....................... CENSUS TRACT ...... <br /> Owner's Name _16 ..................................... .......................I..............Phone ...... <br /> • Address ....................... city ...... .................... ............. . <br /> Contractor's Nome ...................z........License # 4ZZ�%9L.. Phone <br /> Installation will serve. <br /> Residence Apartment House 0 Commercial E]Traller Court 0 <br /> Motel 0 Other ............. <br /> Number of living units-------_--_ Number of bedrooms ......Garbage Grinder .............Lot00, <br /> size .2.4%.... <br /> Water Supply: Public System and name ................................. ..................................................Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay Ej <br /> PoatO -S�ndyLoomo ICI oy Loam 0 <br /> Hardpan Adobe 0' Fill M6terlol ............ If yes,type............... ........... <br /> i - .....— <br /> (Plot plan, showing size of lot, location of system in relation wweils,.bullcllnqs, etc. must be placed on rover" side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If bli sewer I available within <br /> 200 feet,] <br /> PACKAGE TREATMENT I SEPTIC TANKSize_....? t. �o j � ... <br /> ....................... ...... Liquid Depth .......................... <br /> Capacity --- Type ...Cov(40weV No. Compartments .......14.......... <br /> Distance to nearest: Well ----- ..............;-Foundation Prop. Line ...140- <br /> LEACHING LINE. No. of Lines .....!­... Length of each line..'....' TotalAength <br /> ......... ........ <br /> V Box ............ Type Filter Moteral lqkC�.....Depth Filter Material Distance to ............................... <br /> est. Well ...160---_------- Foundation ..l ............. Property Llne .*11V....... <br /> SEEPAGE PIT Depth ......0_1� - Diameter 41-WINK.. Number. ........ .......... Rock Filled Yes NO 0 <br /> Water Table Depth -- _---------- fi <br /> Rock Size ...... <br /> Distance to nearest: <br /> Well ........................Foundation <br /> .................. ....foundation .... <br /> REPAIR/ADDITION(Prev. Soni Prop. Line ... <br /> Sanitation Permit ........ ............ ----------------- Date ...4................... ....... <br /> Septic Tank (Specify Requirements) `•--- <br /> Disposal <br /> ----Disposal Field (Specify-Requirements] ................. ............................... ............... <br /> ---------- ----------- ------ ...............1­1........................I................... ...... ........ ......................... ------ ............... ............. <br /> ( <br /> --------------------------------------------------------------1-1----------­------­ ------------_.. --------- <br /> ........... ..........I.............. <br /> -Draw existing and required addition on reverse-sido)-----------*.............. ... <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health,District. Nome owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which thispermit Is Issued, I shall n.at employ any person In such manner <br /> as to become s ject-io Workman's Compensation laws of California." <br /> Signed -------- ----- Owner <br /> _---------- ............ — -------------------------- <br /> BY - <br /> ----------------- <br /> *...... Title ............... <br /> (if other than-owner) . ..... <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... C11 <br /> ­----------- ... .......... <br /> 7il: ..........................I---------------_­------------- DATE <br /> BUILDING PERMIT ISSUED ....................... <br /> ----------------------*------- -----------------------*---------------_DATE ..... .......... ........................ <br /> ADDITIONAL COMMENTS -------------- <br /> ------------------------ --------------- ---------------- <br /> -----------------A­1-------------I.. ..... ------ -----------__--- ........ ---- -------- ------- ------- <br /> -------------------------I------------- ---------------- ----------------------------------------- ---------­------- --------------- --------- ...........I----------- <br /> ............................... -- ----- ---------- <br /> ------- ------------ ­----------------- -- ---------------- ------------- ........ ......I------ -/.............. <br /> Final Inspection by: ..... <br /> ­ -------------------------------------------- ........ --------------- ...Date .3Z,�Z_;:? <br /> ER 13 2� 1-68 Rev. 5m �6� -,?--_------------------ <br /> 1/11AAN JOAQUIN LOCAL HEALTH DISTRICT 3M <br />