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------------------ ----- --------------I---------------- APPLICATION FOR SANITATION' PERMIT <br /> ------:------------I................. (Complete In Triplicate) Permit No. <br /> ............................... This Permit expires I Year From Date Issued Doti issued 77 <br /> 7­1­ ............. .......... <br /> Application is hereby made to the Son Joaquin Local Health District for a permit <br /> 5japs EW4 ZA he work herein <br /> described. This application is made in compliance with County Ordinance No. stl affidt Regulations- <br /> JOB ADDRESS/L9G4TION ",'-5'2_J_ <br /> ....... ... ......... .....CENSUS <br /> Owner's Nam TRACT ......... ................ <br /> 4-�-­ ....... ................ .......... ..........Phone <br /> Address <br /> ........ .. <br /> 1, 1 ...... ..... _SL............ City ........ ...... ....... <br /> Controictor's Name <br /> ---------- <br /> .......License # <br /> Phone ....................... <br /> Installation will serve, Residence[3Apartment House 1E) Commercial Cyrrallgr coutt 0 <br /> Motel 0❑Other.------- ........I.......... ........;...... <br /> Number of living units:-.._ ..... Number of bedrooms Grinder ............ Lot size ...11 <br /> Water Supply. Public System and n .... -—------------ <br /> ...... . <br /> name <br /> .El Silt 0 .......I <br /> .................................... ...........Private <br /> Character of soil to a depth of 3 feat: Sand <br /> Cloy C1 Peat❑ Sandy Loom Clay loam 0 <br /> Hardpan El Adobe 0 fill M6terIoI ............If yes,type ............ ...... <br /> Mot pion, showing size of lot, location of system in relation to wells, buildings, etc. must be <br /> placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer Is available within 200 feetj <br /> PACKAGE TREATMENT SEPTIC TANK Size................................................. Liquid. Depth .............. <br /> Capacity Type .................... Material......_....------...__ ............. <br /> No. Compartments ..................... <br /> Distance to nearest: Well --------_------------ ..........Foundation .................. <br /> Prop. Line ..................—, kp <br /> LEACHING LINE No. of Lines _..............I........ Length of each line........ .................... Total Length ............................ <br /> V' Box ............ Type Filter Material <br /> ...... -----------Depth Filter Material ....... ....... <br /> Distance to nearest, Well ................ ....... Foundation ..... ..... .... Property Line ...... ...... <br /> SEEPAGE.PIT Depth ­­--------------- Diameter ................ Number ........._ -Rock'Fil <br /> ................. led Yes' 0' Na <br /> Water. Table Depth ............... ........ <br /> ----------r—...........Rock Size <br /> Distance to nearest- Well .................I......................Foundation ..................... .Prop., Line........................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .............­­------- <br /> ......... ............ Date ....................... <br /> Septic <br /> .. Tank (Specify Requirements).--------------- ................. <br /> ................ <br /> ---------- <br /> --------------------........................ <br /> .............. .............. <br /> Disposal Field (Specify Requirements) <br /> ----------------- <br /> -------------------- --- ---- .....�r <br /> -------i6r--------------­ - <br /> ------------ --------------------...--••-- <br /> -----------­---------------------11...... ................................... ............. ............ <br /> aw existing and required'addition on reverse side) <br /> I he,reby 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 Health01strIcI. No <br /> sed agents signature certifies the following: me owner or 11cen. <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 /> as to become subject to Wo r"n*s Compensation laws of California." <br /> Signed ---- -------- .............. <br /> By --------------------------- --- ......... Owner <br /> ........ litle __Ce� <br /> (If other than owner) .. ................... <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED Ely <br /> BUILDING PERMIT ISSUED --- --------- 7------------------ <br /> ADDITIONAL COMMENTS ---------------------------------------- ....... ......... ......... - --------- -----------DATE . --------- - ----------- ....... <br /> .....1­1........................... ......................... -------- ------­.............. ­ <br /> --------------------- -------------- ---- ------I-------- -------1-11--------------------------- ---------- ---- ............................ <br /> .........._-------------------- ----------:--------------------- .......... ....... <br /> ---------------------- ----------------- -------------------------------------- ---------­­......... ------ ----------- <br /> Date ......1007 ............ <br /> - ---- - - ------- ----- --------- --- <br /> FinalIns ----------------*-------- --------------------------------- ----------------------- ---- ------- -------------------*-------------- ....... <br /> ---------------- ........ ................. <br /> EH 13.2L 1-68 ilea. 5m SAN -----JOAQUIN LOCAL HEALTH DISTRICT 8/7. 3M .......... <br />