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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT d <br /> Permit No .......... <br /> {Complete In Triplicate} <br /> '.......�.!. .. ..................... This Permit Expires f•Year from Date Issued. _ _ W. � �. Doti Issued ....... <br /> .....7..7 <br /> Application:is-hereby made to the Son Joaquin local Health District for a permit to construct and install the work heroin <br /> described.This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAJX*,4 ......��Z........ 'L.�.�.�..-......................CENSUS TRACT ........................... <br /> r <br /> !.Owner's Name ...-`- J.................Phone ......... ....................... <br /> _................Address ... .. <br /> Contractor's Name ...� �..........License <br /> ill ............................. <br /> Installation will serve: Residence Apartment House 10 Commercial OTrailer Court �] <br /> Mate]❑Other..._.. .. .. dries <br /> Number of living units:.-•-• _-_-- Number of bedrooms ......Garbage Grinder ............ Lest Size ....................... ............... <br /> Water Supply: Public System and name ...........................::....._.....:...:.:.::..:..:...:..:...........:........:..Private��: <br /> Character of soil to a depth of 3 feet: Sand 0 It Q Clay Q Peat Q - Sandy Loa ML Q Clay Loam Q <br /> Hardpan 13 Adobe Q Fill Material ............If yes,type;.......................... <br /> (Piot pian, 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 so". .1 pit permitted if ublic sewer is available within 240 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK Size.�i��h?:.��.�,���....�........... Liquid Depth ...�................. <br /> Capacity .E. a- -..... Type Material. y .-:... No.. Compartments v.. .................. <br /> Distance.to nearest: Well ...........XA ...........Foundation _1.0.44..... Prop. Line... ........ W <br /> LEACHING ZINE [q.1 No. of Lines . ... ............. Length of each line..:....; 1 ........... Total Length .............. <br /> 'D'. Box .._.1.:..... Type Filter AAateriai .........��.... Depth Filter MaterialT;....�9.. .............................. <br /> Distance to nearest, Well ...... Foundation ...... Property Line ...... .Y....-..(p <br /> SEEPAGE PIT [h : 'Depth ..,_Zt�... Diameter .-_. 3"_ Number .........fir......-..... Rock Filled Yes ENo C30 <br /> Water Table Depth ........V.0_0: Rock Size ..l_��..X..��.......... <br /> Distance to nearest:Well ........x.80... -.....:.:...Foundation Prop. Line ....s. ...... <br /> REPAIR/ADDITION(Prov. Sanitation Permit# .................... ........................Date .............................:.....) <br /> Septic Tank (Specify Requirements)._.,....,.........:........... •_.... ..._..-••---•............ ._....................................._ ............. <br /> Disposal Field (Specify Requirements) .........•......................--•...................................... ................ <br /> ..........•...... .............. ------•••-•••-------•---------------•---.._.._.....---•-••.........-•---........---•-•-----.........:....._............_..........---:........._..--•••.................. <br /> ......................................................................--.............................-............................................................................................. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the workvAll be done in accordance witk.San JmKidn <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.iilistrid.Horne or or iicm <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 empkry any person in such manner <br /> as to become svblect to Workman's Compensation laws of California." <br /> Signed................•--•--••••••••-•-.....--••-••.......••--..._ ................:._ Owner <br /> . 3itie _...._.............:...... <br /> BY ----....---••-.. ........................................... __.........--••-•• .... ............... <br /> (If other than owner] <br /> FOR 010ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... : . ............ ...... .......,:.DATE...^: <br /> BUILDING PERMIT ISSUED ... ............. <br /> - - :_.. .................................................. DATE.............. <br /> ....... . <br /> ADDITIONAL COMMENTS ........•------••--_... .....................:..........I................ <br /> .............................................•-----.........---------................•----....I..---...---•--...........---..................._................---................-••.................... <br /> -•----•--- --------•-•-•-----...-- •------•...............•-•-----=-•----•---.........----------------------••-•----....-----------.....-•--••------...------ ------------ <br /> .....-------......... <br /> .._....... <br /> ---------------------------- ------ --q.�( .._.................................................---......... , .............I... ........ .................... <br /> Final Inspection by: C: .............................................I...............Date .� �.............•.7........... <br /> EH 13 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3H <br />