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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................................ ................ <br /> • <br /> (Cornplete-in TofP liceto), Permit No. ./. <br /> ..........I.............................................. . <br /> ..................I....... ............ ......... This Permit Expires I r Year From Date Issued Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to constrt;d and Install the Work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA,TION ....i..I:q_q.l..__.�.Am... <br /> ................... ....................CENSUS TRACT ......... .......... <br /> Owner's Name .... .............b-0.4?� ...................7....................­--..............................................Phone ....-................................ . <br /> Address ......................................city ............................. ---—1-------- <br /> Contractor's Nome .6-f-e—jq�.,qPA . .....................License# ••---------------------- Phone ...3.4-AF.--W <br /> In. stollotion will.serve i.. Residence UJ4<partment House C3Commercial OTraller Court C] <br /> Motel [3 Other.......... -------------I................. <br /> Number of living units------------- Nuifiber of bedrooms -2---Garbage Grinder .......... Lot Size -...-------------------- ................. <br /> Water Supply: Public System and name ............................._...r_..•........._.____._- ....................... __..__....Private <br /> Character of soil to a depth of 3 feet: Sand[]. Silto Clay E] Peat Ej Sandy.Loom Clay Loom 0 <br /> Hardpan C] Adobe 0 Fill Material ............ if yes,type ............ ........ <br /> (Plot plan, showing size of lot, location of must be placed on reverse side.) <br /> NEW INSTALLATION. (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size................................................ Liquid Depth .................... <br /> Capacity -Iaoo�a_ type <br /> ...... 7 ............... <br /> .... Material ec'MACIt., No. .Compartments ' <br /> Distance to nearest: Well :4•.............Foundation J'6j ..f..-T...... Prop. Line ......4 .64Q.-1 -..I -.. <br /> X <br /> LEACHING LINE, No. of Lines ------- --- Length of each line...-----601.__.._.:__. Total Length ...... <br /> D' Box ...I-------- Type Filter Material 1.6-412f.......Depth Filter Material .......... <br /> —7 <br /> Well <br /> -ape ............ <br /> tj <br /> Distance to nearest: ......... Foundation 0.-_1... -property Line <br /> SEEPAGE PIT Depth ----4R ........ Diameter 33_....... Number ......* ........... <br /> 2 . <br /> � Rock Filled ' Yes' No <br /> . . <br /> Water Table Depth -----------......................Rock Size /X.......• <br /> Distance to nearest- Well ....L11P..........................Foundation Foundation .t Prop ....... <br /> F, Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .............. ............................. Date ....... ................7.�....... <br /> Septic Tank (Specify Requ iiementi):....-?.... <br /> --------------7 1................. ..............-t... ..........7--------------------- <br /> Disposal Field (Specify Requirements) ....... <br /> ............ ........................................---...-:-----•----.....-------------- -•---•{.........I............---------------------- ----- --.......... ...........-....... .......... <br /> .......... ........... ...................... ....I....... ................. <br /> ---------------- -------------------- -------I--------------------------- <br /> ------------ .....---------------- ............. ......... ......... .............. ................ <br /> (Draw existingan required addition on reverse side) <br /> I hereby certify that I have prepared this applic4iflon' and thin-the work Milli'L be'done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local HeallW811strict. Horne owner or licen- <br /> sed agents signature certifies the following: <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 Workman's Compensation laws of California." <br /> Signed ----------- - --------- --------------------------- Owner <br /> Title ..................................... <br /> ---------------- --------------------------- <br /> 'cher than owner) <br /> FOR DEPARTMENT�USE ONLY <br /> - - - ---------------- <br /> ............................... DATE.--r--./, ............... <br /> "-•-"---._..."--------•"-•"""-------------------•----""-"--- <br /> ...............___..................................................................DATE ....---------•---------------------------- <br /> ------------------------\ ............................................................................------------------------------------- <br /> .............•---..__....---.._------..----.-----------------------------1--------------------------------------------------------------- <br /> ......................I..............- .4----M,�-..............7 <br /> ..............-- ,—...... ..................... ~Z'S.--... 1--.-I, <br /> QAQIJIN LOCAL HEALTH DISTRICT 8/74 3M f,, <br />