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FOR OFFICE USE. FOR OFFICE USE: <br /> . .....— <br /> APPLICATION FOR SANITATION PERMIT ;77- p13 <br /> Triplicate) Permit No----------- ----------- <br /> .(Complete in Tri <br /> , , I <br /> ---'-•--'••-•..._.....-'-....._._._......._....,. • Date <br /> ...............-............. .................... This Permit Expires I Year From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations:. . <br /> ...... CENSUS TRACT.......... ...... <br /> JOB A6DRESSAOCATI&N.... ...... <br /> a,i�_.E........... <br /> '441 ,,­*-------- i, 1� , . <br /> -_------------ ------ ...... ... ... - - ----------- <br /> Owner's Name.. 1. .. <br /> �7. <br /> ----------_-----_- <br /> .. ....9 ........ city...... ................. ..... ------------Zip-_ <br /> Address-_.:................... <br /> Contractor's Name_ ---------License #. .. <br /> ---- ----Phone . ........ <br /> + <br /> - <br /> Instollati6nwill:serve j?;" <br /> Resije�ceAp Cort;merft House,E] Commercial ❑ Trailer Court,' <br /> Motel J , . <br /> .- 7 - . <br /> M -Other--•---J----------------------- <br /> 'of ........ <br /> Number of living units;..J./_i__._..NuM bet bidrooms-'..P!?�:fGdr'ba.ge.Gr�nde LoEsizel___._� <br /> ----------------------------�t:.......... ---------- <br /> Water Supply.,Public System and .........I----------Private <br /> Cherocter of soil to a depth of 3 feet: Sand E] :Silt 0 Clay,[13 Peat 11 Sandy k?crn -,CIcy Loam ❑ <br /> 7 ► <br /> Hardpan E] Adobe yes,type Fill M t' i0j-' .................... <br /> i Y <br /> ,.- <br /> (Plot plan, showing size;f lot, location of system in relation to'.wells,buIIdings,:etc..mtjst be,placed on reverse side1.) <br /> II r . ..,A . �. 7 <br /> J <br /> NEW INSTALLAtION-­* �jNo.,septic tank�br seepage' pit permitted if public sewer is available within fiet) <br /> Size ....... .. .. .............. <br /> TREATMENT SEPTIC TANK [4 <br /> PACKAGE Depth <br /> C_ap6city.-.:__!-------------- . -- -- _-----.Na. <br /> Compartments------------- <br /> Line. <br /> -Found -Prop. <br /> . . ..... -Distance'to nearest. WeII..4,____....... ........... <br /> LEACHING LINE. each line-,,, <br /> No. of Lines....­,-* .......... ....Length h o�e Total.! Lenjgth.................__...-------t_.._... <br /> _14 gt <br /> epth <br /> 'D' Box.............Type Fi.Iter Material__.._..:- ---------- Material, :---­---------- ............... <br /> .......... <br /> 157=7_o nearest:Well: --------i­ <br /> . .....................Fc�;nd8tion.��............'...__Property Line-..-........ <br /> Yes E) No <br /> Rack Filled <br /> SEEPAGE PIT Depth_ ------;�_,Diarneter. -------V_ ----------- ........... <br /> WaterTable Depth.......... .......2`-------------� ------- --------.!".-.Rock 5 e.._._--=--•---;..._-'---•--.................... <br /> --------------_-Pi6p. Line._:------------------i- <br /> Distance.to nearest: ....... .... .../Foijr;dation <br /> REPAIR/ADDITION (Prev.,San-itation Permit#..._..__. <br /> Septic Tank (Specify Requirements)-- ----- A -- --- ;- ----t:/44,4�0�6 _- ---------------- <br /> Disposal Field (Specify WequireMents)-.......14R --------- ........ ..................... <br /> ................ --------------- ----------------- <br /> ............. .. ------ <br /> -------------------- <br /> ---------- -------......... ............. ....... ---------------- ...... - ­ <br /> ------ -------------- ................ -------_ <br /> (Draw existing and required addition on 'reverse side! <br /> I hereby certify that have prepared this application-and that the work.will be done- in accordance with Son Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District..Home owner or licensed agents <br /> signature cerHfies the following: <br /> "I certify that in the pet4orrrl'ance of the work for whiEh thii permit is issued, t shad 661 employ any persbwtn'such mann,"as <br /> to beco b'ect to rkrnatf I s Compensation laws of California."- <br /> Signec 7- Ow ne-r <br /> f ....... <br /> By.... .. T <br /> ..... . ..itle. <br /> (if other tiicn net) # <br /> L <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY........... ............ .....DATE 7_?2...... ...... <br /> DIVISION OF LAND NUMBER------- ­__­-7,�------------- ------I....... .---- -- ------_DATE ---........ ---------- ----------------------- <br /> ADDITIONALCOMMENTS-------•------- --•-•_ --------------I...................11�_. -------- --------- ------------ <br /> ................................ <br /> ..............:­---------- ................. ---------------------_------------------- ................ ....... ......... ...............­­........... <br /> ........................... --------_-�,*_.................. ......... ..... .............-------­------- <br /> rr <br /> ............ ........ <br /> te- <br /> Fincil Inspechon by: .....!,r- ---- <br /> Da <br /> FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />