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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT II <br />.............. ......................•-••-•--..._..-•-•.: <br /> Permit No. . ............. <br /> lComplete In Triplicate) <br />...jv, <br /> ................... ...............1—........ <br /> -`,"5;;P :7 7...6 <br /> ... ..... <br /> ......-................... ........................ This.Pormit Expires I Year From Date Issued Date Issued ... .... <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 ---- A- - ----- <br /> • 41 & <br /> .714 ..W...f'-4... ... ...I...... C E N S V S TRACT .......11_............. <br /> Owner's Name ..,S�ALAZ .. .. .......................................... ........Phone ... <br /> ---------- ........... <br /> Address 4...j� ........................ city /, R.....----------=--..........!.......-•------•-- <br /> Contractor's Name -----------------------------*................... ...... ..................... .........License # ......... ....... Phone -------—1...... ........... <br /> Installation will serve: Residence 8i Partment House f3 Commercial OTraller Court J-] .1 <br /> Motel 0 Other....................................I........ 11 <br /> Number of living u6its:....J------ Number of bedrooms -,,3....Garbage Grinder Lot Size ........f44 <br /> Water Supply: Public System.and 7..................Private <br /> Character of sail to a depth of 3 feet- Sand Tr Silt 0 Clay ❑ Peat[3 Sandy Loom 0 Clay Loom b <br /> Hardpon[j Aclobeo Fill Material yes,type ......p........ .......... <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 feat,) <br /> ..................... .... <br /> PACKAGE TREATMENT SEPTIC TANK fO Size. ............ Liquid Depth . <br /> Ty Material .......... ........ No. Compartments ... ............. <br /> Cal acity pe ... ............... <br /> Distance to nearest: 1Nell ...........•-----------------Foundation ..................... Prop. Line .............. <br /> LEACHING LINE No. of Lines ------Z5�.......... Len t h'.of each line.... 1 ..../........ Total Length _--_....L..........-•-.-••• <br /> /. <br /> D' Box ...--------- Type Filter Material ..:Depth Filter Material ........ Le'All............................... <br /> Distance to nearest.,Well .................. ..... foundation ........................ Property Line ....li................................... <br /> SEEPAGE PIT Depth -------------------- Diameter .............. Number ------ ..................... Rock Filled Yes [3 (3 No <br /> ' 0 <br /> Water Table Depth ... Ili <br /> ....---•.......................Rock size ------........---••---•-••--•-.. <br /> Distance to nearest: Well ................. ------------I......,...Foundation ------------------.-- Prop. Line 7.. ............... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...........•---------------------------------- Date --------------------------------- <br /> Septic Tank (Specify Requirements) -----------------------------------------------------......................-................ ................. ........ <br /> ------------------- ........ ........ ............ ....... <br /> Disposal Field (Specify Requirements) ...... ..-----------------••------------•------••--•--•------•--- <br /> --------------------------------------------- ------------------­----------- -------------------------------- ................................................ ............I....... <br /> !j <br /> ------------- ------------------- ---------------------------------------------------------- .............--•--.......................................................... .......... ................... <br /> (Draw existing and required addition on reverse side) <br /> 1 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 San Joaquin Local Health:District. Home owner of 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 btinploy any person In such manner <br /> as to become bject to Work o pensation laws of California." <br /> �,;;gr Fn s7!r <br /> Signed -- -- -- ---- -------------------- ................. ----------- Owner <br /> ................. ------ <br /> ;; . <br /> By ---------- - -------I...................................... ................. -Title ......... ------------------------------------•-••.............. <br /> (If other than owner) II <br /> FOR DEPARTMENT USE ONLY <br /> 01 <br /> APPLICATION N ACCEPTED BY "o, -- -L-1 <br /> r �- - PATE ........... ............ <br /> --------- ---------------------------------------- �;j <br /> BUILDING PERMIT ISSUED ----------------------------------------------- - ------------------------------------------DATE----------- ................. <br /> ADDITIONALCOMMENTS -------------------------------------•...... ----------------------------- --------------------------------------------------—... ........ii................ <br /> ...................I...................................................... -----------------.................................... -------- -----------------------------it............... <br /> II <br /> ------------------ ----------------------- ---------- <br /> -----------------------•----------•-------•--....._... ._...---.....-•-----_--....--... ........ --- <br /> -------------------------- Z <br /> ------ ----- ....... <br /> ----------------------------- ------ ------------------ q <br /> Final Inspection by. ---------------- ------ ............. .......Date ........1— <br /> EH 13 24 1-68 Rev. 5M SAN joAQuIN LO AL HEALTH DISTRICT 8/7h:1 3M <br />