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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> i(;ON Permit 14m <br /> ............................. <br /> (Complete in Triplicate) <br /> .......... ................................._ Date Issued ... <br /> This Permit Expires 1 Your From Datelssued <br /> -- <br /> ........................ --- ---------- ----------- <br /> n is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> nty Ordinance No. 549 and existing Rules and Regulations: <br /> This application is made in compliance with Cou <br /> T .......... <br /> -SS/LOCATION2 9 ..... .......... CENSUS TPAC <br /> --- <br /> DRE <br /> V . ......... <br /> Namq, .....................__;,........ Pone........---------- - <br /> Address ....... cii� ..................--------------- <br /> Phone J. <br /> Contractor'i ..... ..... ­_ �4z .License # <br /> installation will serve: EDT <br /> Residence Apartment"House C1 Commercial railer Court 0 <br /> Motel El Other.. ....... ....... <br /> Number of living units:...../_.... Number of beclroom�j.._.___...__Garbage_ Grinder ......... Lot Size . <br /> Private <br /> I ...................................................... ..... .. <br /> Water Supply: Public system and name Clay Loom0 <br /> 1 0 Silt F Peat El Sandy Loam Clay Loam.f] <br /> Character of soil to a"depth of 3 feeti Sand clay 71 <br /> IHardpan rl Adobe'[3 Fill M6terial *71-,elf'yes,type- -----_----------- -----reverse side.) <br /> (Plots plan, showing size of lot, location of system_,in-jelation to wells, buildings, etc. must be placed 'on reve <br /> 1 �4 vailable within 200 feet) <br /> b c sewer NEW INSTALLATION:k (No septic tank 5r'seepagepit permifteaif P7U li� is a <br /> I U------------------------ ... Liquid Depth ............. -------- <br /> PACKAGE-TREATMENT I I SEPTIC TANK I I Size.------ <br /> No. Compartmen'ts .....r............... <br /> I Capacity _.................. Type -------------------- Material------- ----- ----- K <br /> I .... Prop. Line ........... ........ <br /> to nearest; Well .. ....................... ....Foundation -------- .... .... <br /> Distance I Length ........... ...... <br /> LINE No. of Lines ........... ............. Length of each ........._--------?...... Toto I <br /> LEACHING <br /> bep th/ --------- - -- <br /> 1 <br /> . ......4- <br /> ffilter Material --------------- <br /> t 'D' Box ............ Type Filter Material ----------- N,,/ <br /> Distance to nearest: Well .. _:---- Foundation. _ ---- ----- Property Line. <br /> I ............... 1 1, . .. ......... <br /> Nei M / 0 , <br /> ........ Diameter ........... it- r........ ........... Rock Filled Yes ❑ N <br /> SEEPAGE PIT �[j Depth <br /> tWater Table Depth ..... ...... ..Rock Size .... <br /> '^F Distance to nearest; Well ....... ................v.., .......Foundation ....--------.-•.... Prop. Line ...................... <br /> ITION(P�ev. Sanitation Permit# ......... ....... ----- ------ ----- Date ----------- ------------ -------- <br /> REPAIR/ADD] I <br /> --------_-------- <br /> Septic Tank (Specify Requirements) ............ -------------- ...... ...... ---------------- ........ <br /> ?posa <br /> Di' l Field. (Specify Requirements) 4AC_�. .... <br /> ----------------- <br /> ---------------- .................... ....... ..................................................................... .............. ........ <br /> [Draw existing and required addition on reverse side) I . <br /> I her!'.*by 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: for which this permit is issued, I shall not employ any person in such manner <br /> as tobec <br /> "I certify thatI�n the performance of the work <br /> omg u lect�to Workman's Compensation laws of California-" <br /> , Owner <br /> Signed ....... .�_-�V <br /> --------------- jitle ............... <br /> e <br /> By ..-P_..---C.--_ <br /> - - ------...... <br /> "- ----- <br /> (Ifthan ownerl <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .......--------- ------------------- ------- --- DATE <br /> BUILDING PERMIT ISSUED ..----------_------_--- .............. ..................... ....... .......................DATE ..............................-- ...... <br /> .­-------------­---- ........ I --- --- ....... ------------------------_ <br /> ADDITIONAL COMMENTS ----__------- ------ ................................ ....... --- - ---- ­ <br /> .... .................... ................ 7---------------- <br /> ----------------------------------------------- ------- ­-­­­­........................... ------------------------- .. .... ... <br /> ---------------------- -------------------------------------------------------------- - ....... <br /> --------------------- ........ --------------...................... ........................... .. <br /> te ------- <br /> .......'Do <br /> - --- ------ -- - -- -------- - ------ - -_ <br /> - <br /> Final,inspection by; ---------- -SAN---JOA-QU-I-N---LOCA-L---HEALTH- - DIST RICT <br /> E.H. 9 1-'48 Rev. 5M <br />