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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />......... --------••-•--..---•- ............ lComplete In Triplicate) Permit No. <br />...................... ........... ------- <br /> Doti Issued... ..... <br /> ­........... d <br /> 77 <br /> ......................... This Permit Expires I Year From Dot*Issue <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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION CENSUS TRACT ......... ..... .......... <br /> ... ..........Phone ......... ....................... <br /> Owner's Name .... .... .... .......................................................... <br /> City --.----- - <br /> ------- . ........ ........... ........ <br /> Contractor's Name ... :.......license # Phone ..... ........................ <br /> Installation will serve.. Residence Apartment House 0 Commercial C]Traller Court 0 <br /> Motel []Other ............................................ <br /> Number of living unitsNumber of bedrooms .....Garbage Grinder .............Lot Size ... 5... ......... <br /> Water Supply: Public System and name .............­............ ........Private <br /> ...............I........................I........... ..................... <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay [:]. Peat 0 Sandy Loom 0 Clay Loom 0�— <br /> Hardpan 0 , Adobe 0 Fill Material ............ If yes,type ................ ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit .permitted if public sewer is available within-200 feetX <br /> PACKAGE TREATMENT SEPTIC TANK jpf ... ............. Liquid Depth ..... .................... <br /> Capacity - k _a__------ .......... <br /> _f�-------- Type Material-----L"? - ... No. Compartments <br /> Distance to nearest: Well ------------ .._.._._....Foundation ..... Prop. Line .,-I.— <br /> LE ACHING LINE fk( No. of Lines ........_3__._ __.__ Length of each line....._.... Total. Length ... i`....... E <br /> 'D' Box Type filter Material ........5.g....Depth Filter Material ...41............................. <br /> Distance to nearest: Well ........LPPJ,x:. Foundation <br /> J.v_ Property Line <br /> No <br /> SEEPAGE PIT [_Orl, Depth ......9P_4.Lt Diameter ---q 2—`---- Number ........ ..... Rock Filled Yes Or" cj3 <br /> Water Table Depth ...............+.fPJJ....................Rock Size ..Li/P.....1-3..-.. <br /> Distance to nearest: Well ----------------------JJ.............foundation __-_f..0- Prop. Line <br /> REPAIR/ADDITION Wrev. Sanitation Permit# ... ------------ --------------------------- Date ..................................I <br /> Septic Tank {Specify Requirementsl----­-------------­ ...........:......... .................................... ....................... ......................... <br /> Disposal Field (Specify Requirements) ------------ _---_------------------­­........­­..........................................­­_................ <br /> ------------ .......I——--------------------------------------------------- ­----­----I-------------­----------------------------------------- .............................. <br /> --- -------------------- ------------------------I-------I——------------------------------ .......................................................I——.................................... <br /> (Drow existing and required addition on reverse side) <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. Home owner air 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 /> 14- . .... . ........... Yitle _._&......­- -—---------­ ....... <br /> ........... <br /> By ........ ............................. ..... ------ .......... <br /> Ilf other than ownerl <br /> FO DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY ............. � X/' <br /> .•----.--.--....._._._ - ; ------------- DATE ...... <br /> `BUILDING'PERMIT" ISSUED"_--........­---------------------------------------------------------------------------------- ...,.-DATE .... ---------------_ -------..._..- <br /> ADDITIONALCOMMENTS ..--• ----------- ------------------------------------------------------------- ------___--- -------7........ .................................... <br /> -------------------------------------------------------------------------------------------------------------­_­-----------------------------­........­­............................__ _........ <br /> ........................I---------- ------------­-•----------'•--•---- ...... ---------- --------...----•----•............-•--..-------••-- .................. ............... <br /> 2 <br /> ...................... ......Date .. ......r............ <br /> -4--------------------- ........... ----------------------- ------ <br /> Final Inspection by- --------------- ------ <br /> ....m.......... ........ ------- <br /> 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> E-'H'----1---3-*- --------­---- <br />