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O OFFICE USE. <br /> 7 APPLICATION FOR SANITATION PERMIT Permit No <br /> (Complete in Triplicate) <br /> This Permit Expires I Year From Date Issued Date. Issued <br />);,fit rition is hereby rno ii, to the Son Jonquin I r---II Health District for a permit to construct and install the work herein <br /> 5,ribecl. This applicoi;;n is made in compliance with County Ordinance No 549 and existing Rules and Regulations: <br /> M ADDRESS/LOCATION &�,.')' % CENSUS TRACT <br />".,ner's NamePhone <br /> 17 .. <br /> k. <br /> Mross & "ity 5-41 <br /> mtrcictor's Name ✓ jc- fLicense# Phone <br /> Vjr F(',em:ro Vq q <br /> stallation will serve: Residence[71 Apartment House❑ Commercial [-]Trailer Court <br /> Motel []Of h I-r 4,"), <br /> imber of living units: Number of bedrooms Garbage Grinder 00 Lot Size <br /> ater Supply: P- blit System and name "t?;Y? 7.r...L ..Private <br /> ion atter of soil to a depth of 3 feet: Sand ❑ Sift❑ Clay E] Peat C] Sandy Loom 0 Cloy Loorn ❑ <br /> Hardpan❑ Adobe%, Fill Material If Yes, type <br /> of plan, showing size of lot, location of system in relation to wel . buildings. etc. must be placed on reverse side.) <br />'W INSTALLATION: (No septic tank or seepage pit permitted if p4b!l!iF sewer is avail .e within 200 feet,) <br /> kCKAGE TPEAT,.1ENT [ ] SEPTIC TANK r I Size. 11i"I'l Liquid Depth ..... .. .. ...... .. <br /> Capacity Type MGter�l(.'-'CAP&e/r No. Compartments . .......... ....... <br /> Distance to nearest: Well lr&x* .,44.1�... -Foundation Ile . ....... Prop. Line .. ........ .... <br /> dd <br /> ACI IING LINE No. of Lines Length of each line rO r Total Length . .... <br /> 'D' Box Type Filter Material YfZctlf, .. ..Depth Filter Material <br /> Distance to neorrst! <br /> Welly !/Foundation Property Line <br />[PAGE PIT f Depth 1�2f— Pitc6� ✓ Nmbe- 461V If Rock Filled Ye.; No C) <br /> N <br /> Water Table Dept"I .... ....i.Rock Size <br /> Distance to nearest: Well ... . ....Foundation mo. Line ...................... <br />"rAIR/ADDITION(Prcv. Sanitation Permit 6 Date ............. ... I <br /> S-ptir Tank ISr(-c-;fy Requi.ement,.) <br /> Mspcsal Field (Specify Requirements) <br /> (Drn,,v r,6stinq and required addition on reverse side) <br /> icreby certify that I have prepared this applitnticr. and that the work will be. done in accordance with Son Joaquin <br /> wily Ordinances, State Laws, and Fules and Regulations of thr- Son Joaquin Lncnl Health District. Home cwne, of licen- <br /> d agents signature certifies the following: <br /> certify that In the performance of the walk for whicl- this permit ;s issued, I shall not employ any person in such manner <br /> i hocomo bf t I Vlorkmari'v, Connppnint;cn laws of Colifornin." <br /> Owner <br /> Title <br /> (1'other than owned <br /> FOR DFl'A ;USE <br /> JQL <br />'t'.;CATION ACCEPTED bY DATE <br /> In"J(-, PERMIT ISSUED DATE <br /> .ion hy, Dot, <br /> �C/ y/�'� '.• _�. <br /> f 10C.At. 14EALTII DISTRICT <br />