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--------FOR 0FFICE U 9 E <br /> -------------------•----- APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Triplicate) <br /> ------------------------------ --------------------------- <br /> Gay-7 <br /> --------------------------------- ------ This Permit Expires 1 Year From Date Issued Date Issued -- ------------- <br /> Application is hereby made to the Son Joaquin Local Health District for a per'mit 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 /> J <br /> ----------- <br /> JOB ADDRESS/LOCATION _!57 -------------------------------------------- ---- ---- ----------,!CENSUS TRACT <br /> dOwner's Name .-ec- -n-L ------ -------e- ---------------------------------- -------------------Phone --------- <br /> ff <br /> Address (n---------------- --------------- City ------------- 0 ------ <br /> Contractor's Name -------(1? 14 - <br /> ------License # _9VY/3--'Zt�Phone 5� <br /> Installation will serve. Residence F7Apartment House,E] Commercial :[:]Trailer Court E] <br /> Motel [:1 Other - ------------------------------------------ <br /> Number of living units:___- Number of bedrooms 3--------Garbage Grinder ------------ Lot Size <br /> - /---------------------- <br /> Water Supply: Public System Land name ------------------------------------------------------- -------Private El--------------•-------------------------------- <br /> Character of soil to a depth of 3 feet: Sand'] Silt❑ Clay R Peat [I Sandy Loom � Clay-Loam E] <br /> Hardpan E] Adobe E] 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 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK[ Size________-_______------ -- -------- ---------- Liquid Depth ____-- <br /> Capacity --------------------- Type -------------------- Mate lal--------------- ------ No, Compartments -------_------------ <br /> Distance to nearest; Well ------------------------- ----------Found ion ---------------------- Prop. Line -----------------------tj <br /> LEACHING LINE No. f 'Lines ------------------------ Length of ach line--_-- -------------- ------ Total Length - -------------------------- <br /> 10 <br /> 'D' Box ------------ Type Filter Material -------------------- pth Filter Material -------------------------------------------- <br /> 11 <br /> Distance to nearest: Well ----------- ----------- Foun tion ------------------------ Property Line ---------i--------------- <br /> 0. <br /> SEEPAGE PIT Depth ------------------- Diameter ---------------- N ber ------------------- -------- Rock Filled Yes M No C1 <br /> Water Table Depth --- ------ ---------------------- ------------Rock Size -------------------------------- Z7 <br /> Distance to nearest: Wel ---------------------- _________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit 90 ------------------------- ------------------ Date ---------------.------------------1 <br /> SepticTank (Specify Requirements) ------- ---------------------- -------------------------------------------------- --------------------------------------------------------- <br /> Disposal Field (Specify Requirements)equirements) ------ --------------------- t -------------------------------------- ------------------ ------------------- <br /> Tx //Vso" <br /> ----- -------- ------X------------ <br /> -------- ------ ---- <br /> 11------------------------------------------------------------------------------------------------------------------------------ -1------------ <br /> (Draw existing and required addition on reverse side) <br /> I herzy 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 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 W r man's Compensation laws of California." <br /> Signed ---------- ----------L,-----t_ ----------------- Owner <br /> ---------- <br /> By ------- - --------- -C Title ------------------------------ ---- ------------------------------------ <br /> - -- -- ------------ -------------------------- <br /> (if other than owned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --T- f ------ <br /> -- ---------- - - - - ------------------------------------------ --------------DATE ------- <br /> ----------------- <br /> -------- <br /> ADDITIONAL' COMMENTS - -- - - ---- -- -- - -BUILDING PERMIT ISSUED .!- - -- - --- - - -- -- --- -- - -- -------- - - - ------DATE <br /> ------------- -- ---- -: -- ---------------- <br /> - <br /> -----------------------------------------�--------- ------------------------ -- - ------- <br /> -------�` V - ---- ------------------ -------------------------------- / <br /> ----T--------------- <br /> - / <br /> Final Inspect-o ----- - - ..Date <br /> SAN ---------------------- <br /> - <br /> - <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />