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'FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No. <br /> ................ ....... <br /> ........... <br /> ...... ­------------ J This Permit Expires I Year From Date Issued Date lss6ed <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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION'. ..... --------- .......... .......CENSUS TRACT ..`..`...................... <br /> iW.'1;0 <br /> Owner's Nome ....... <br /> Phone " ";.. ........ <br /> Address <br /> �..­_­­........... ........ city ... ........... .................. <br /> Contractor's NomePhone <br /> -License # <br /> Installation will serve: Residence d?l Apartment Housef] Commercial E)Trailer Court 0 <br /> Motel0 Other ..._....------------------------------------ <br /> Number <br /> ................_......._--------------- <br /> Number of living units:........ Number of bedrooms ---Garbage Grinder Lot Size .... ........... <br /> Water Supply. Public System and name ._.-_..•-._--• ---------- ........................ Private ❑ <br /> ' * _ :1 <br /> Character '1Z <br /> r of soil to a depth of 3 feet. Sand 0 Silt 0 Cloy El Peat[D Sandy Loom ❑ Cloy Loom ❑ <br /> Hardpan ❑ AdobeFill Material If yes, type ............ .......... <br /> {Plot plan, showing size of'lot, location of system In relation 16wells, buildings, etc'. must be placed on reverse side.) <br /> f public sewer is available within 200 feet,) <br /> NEW INSTALLATION:' (No septic tank or seepage pit permitted i "N. <br /> PACKAGE TREATMENT SEPTIC TANKX Size... ........ Liquid Depth...._ <br /> Capacity L . <br /> 0. Type-.,0. Material_64. 70�. No. CompCompartments .............. <br /> Distance to nearest- Well .......................Foundation......._Foundation ....... Prop. line <br /> 01 1 — <br /> LEACHING LINE No. of Lines ..... Length of each line._...A'/0...I- ------ Total Length <br /> 'D' Box Type Filter Material ------- Depth Filter Material r_ <br /> . .. .......... ........ <br /> .-I <br /> Distance to nearest: Well ............ Foundation ........... Prio�pbrty Line ...... <br /> SEEPAGE PIT iV Depth Diameter <br /> Number ........ ..... .kock,Filled Yes 21 No C) <br /> Water Table Depth ...............9t9_._..-.-_------. -.----Rock Size ....._..a2.0....._._.._......:_ <br /> Distance to nearest. Well ..... ______________Foundation _......... Prop. Line .......e2. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...................... ........ Date ....................................I <br /> Septic Tank (Specify Requirements) ... ........ ............... ----- - ----------- ------------------------------ <br /> Disposc(l Field (Specify Requirements) .........Jlf-to -—----- ........ <br /> ............................ <br /> ... ....... .............. .................... .................. <br /> --- ------- - ................ ......... --------­...... ------------ <br /> lDrcfw existing and required'additi66–on reverse sided — ' <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. Nome owner or licen. <br /> sed agents signature certifies the following':.k. <br /> "I certify that in the performance of the-'W_,ork­fiir_ which this permit is issued;i�ihciffl not employ any person in such manner <br /> as to become subject to Workman's Compe;scitio; li_wi of Caillforniii?" <br /> Signed .... --------- Owner <br /> 6--------- ---- ------------- ------ ...... ...... ............. <br /> By .............. I...... <br /> --- Title <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _l .............­......... ........... .. .......... DATE ...... ......... <br /> BUILDING, PERMIT ISSUED ..... ............ .................._....................................... _.......DATE ........... .......... ............ <br /> ADDITIONAL COMMENTS ... <br /> --------------------------------------- ------*..................................................................... ------------ <br /> ........... <br /> ......................-.1111......... ................. ------------__------ ........._ ................... ....... ----------- ....... .....-.-.-11...... <br /> ............ ------------------- ............... ------------ ................ ------ .........I....... - - --- <br /> Final Inspection by: ------ . . . ................•--------------------------------__------ ......_..._._Date ........ ------- --- <br /> ............... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 1-3 24 1 -'68 Rev. 5M 7172 3 & <br />