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FOR-OFFICE USE: APPLICA71ON FOR SANITATION KzRMIT PemlitN,. <br /> ................................ ---------- (Complete in Triplicate} rr <br /> ...................... Date issued <br /> This Permit Expires I Year From Data Issued <br /> ........................... <br /> Application is hereby made <br /> I Health District fora permit to construct and install 'he work heraii <br /> to the Son Joaquin Loco ith County ordsr-once No. 549 and existing Rules and Regulotions.. <br /> described,This application is made in compliance w <br /> .A61 .......CENSUS TRACT ......................... <br /> JOB ADDRESS/LOCATION <br /> ..Ph oneV0 <br /> A..... ........ ............. <br /> Owner's Nome .......... <br /> >� -7 .................. <br /> ..17,fz <br /> re ........... city <br /> ........Licen'ie <br /> Address ........... <br /> Contractor's Nome <br /> Instaliction will serve- Residence 0 Apartment HouseO Commercial g7trailer Court <br /> ❑ <br /> Motel [:]Other...... f ........ <br /> ......................... <br /> ._.•---...._Garbage GrInder ........ ... Lot Size - ----------- <br /> its............ Number of bedroom <br /> Number of living un <br /> Private <br /> ❑ <br /> ..... ..... <br /> �ilter-Supply: Public System and name .......................................................•..._.........._-.. <br /> Silt 0 Clay Peat C] Sandy Loom ❑ Clay Loarn C1 <br /> Character"of roil to a depth of 3 feet; Sand 0 <br /> ......... <br /> Hardpan <br /> Adobe Fill Material ------------If Yes,type................... <br /> reverse showing size of lot, location of system in relation to wells, buildings, side.) <br /> etc. must be placed on <br /> (Plot plan, <br /> NEW INSTALLATION. (No septic tank or seepage pit permitted if public --ewer is available within 200 feet,] <br /> Liquid Depth. ......................... <br /> PACKAGE TPEATMENT SEPTIC.TANK Size..........................................•----. <br /> ........... .... . <br /> Capacity ...... . .......... Type -------------------- Material........ ........... No. Compartments ..... <br /> ....... Prop.Line ........... <br /> a nearest. Well ...............""___.._........._...Foundation... <br /> Distance t ............... ..............Found, <br /> LEACHING_.G LINE No. of Lines . ........_............. Length of each.line ........ ......I........... Total Length .........................7-, % <br /> De th Filter P!aterial ........................................ <br /> V Box ........... e <br /> Type Filter Material <br /> Distance to nearest. Well .................... ... <br /> Foundation ....... ................ Property Line ............. ....... <br /> Depth Diameter <br /> Numbe. ............................ Rock Filled Yes ❑ No 0 <br /> ............. ...... ................ <br /> SEEPAGE PIT <br /> Water Table Depth Rock Size ............................... <br /> Distance to near'esh.Well ................... .....................Foundation ................_ Prop. Line ...................... <br /> REPAIR/ADDITION(Prey. Sanitation Permit 0 -------- ...... ....... __._ Date —...-..__....----._....---•._."-}, <br /> .......... ................... ............. <br /> ify Requirements) .... .............. ....................................................... <br /> Septic Tank tSper .............. ...... <br /> ments) ....... <br /> Disposal Field (Specify '?equire .. .... <br /> ........................... <br /> ........... ....... <br /> ............... ................... ... .........I............................ <br /> ......... ........ ................. <br /> .. ...­........... ........ <br /> ................ .......... ..... .. ..... ............I.......11................... ..........rse..side) <br /> . <br /> (Draw existing and required addition on reve be done in accordance I hereby certify that I have prepared this application and that the work will with Son Joaquin <br /> Local Health District. Home owner or Ilcen- <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin <br /> sad agents signature certifies the following: <br /> .1 certify that in the performance of the Work for which this POrrelit is issued, I shall not employ any person in such manner <br /> Jews of California." <br /> Ject I <br /> as 10 become sub .0 Workman's Compensation <br /> ­ <br /> Signed ................ ... <br /> Owner.... .... <br /> Title .... .. .. .................................. <br /> BY .............. ..... . .. ....... <br /> {If other n owner) <br /> FOR DEPARTMENT USE ONLY <br /> 7 <br /> DATE _R�� <br /> h , ... <br /> ............ . ...... <br /> APPLICATION ACCEPTED BY .. . . ....... <br /> . ...... DATE <br /> BUILDING ISSUED NG PERM .. . ... ... ... . ..... ................................. <br /> ADDITIONAL COMMENTS ..... . ..... ..................... .. .. <br /> ........... . ......... .......................... <br /> ................... . .......... .. ...... ........... ........ ........... <br /> .................. <br /> .......... ........ . J�j 7--- <br /> ......... Dote <br /> Final Inspection by: ........ ----- ---- ----- <br /> SAN JOAQUIN LOCAL HEALTH-NSTPICT <br /> E.H. 9 1-'68 Rev. 5M <br />