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FOR Offia usE: APPLICATION FOR SANITATION PERMIT <br />................................. (Complete in Triplicate) <br />This Permit Expires I Year From Date Issued, <br />FOR OFFICE USE-. <br />Permit NoJ.7.,:.J.4 <br />Date Issued.477_.V .. <br />e construct c <br />Application is hereby made to the Son Joaquin Local Health District for a permit m iit to constru and install the work herein des,ribed. <br />This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br />J— ............. .., ...,,.,CENSUS TRACT <br />OB ADDRESS/ LOCATION <br />Phone ......... ... .. .. <br />Owner's Name <br />Li <br />........... .. .... - <br />Address ..... . <br />License <br />C <br />Contractor's Name.. _Phone, -.3 <br />Installation will serve: Residence �' Apartment House Commercial Trailer Court 0 <br />Motel --] Other, __.... ....... ...... <br />.... <br />Number of living units:.... /..-......Number of bedrooms -3 ... Garbage Grinder ...................... <br />Water Supply: Public System arid name.... .......... ____ ....... ..... .. Private <br />— <br />Character of soil to a depth of 3 feet. Sond ❑ Silt [] Clay F� Peat E. Sandy Loorn Clay Loom 7Lj <br />Hardpan T-1 Adobe 7 Fill Material...._......lf 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 isaVoilable within 200 feet). <br />PACKAGE TREATMENT SEPTIC TANK Size_ ....... _ ........ ....... ...... Liquid Depth <br />Capacity.......-. ........ ._,Type.,.-.. .... .... <br />....Material... ....... No. Compartment <br />Distance to nearest.. Well.. Foundation.... Prop. Line_ .,..:..........------- <br />LEACHING <br />........------- <br />LEACHING LINE t j No. of Lines. .......... Z <br />Length of each ling Total Length... ..... . ................... ...... <br />Box__.._ -..,.Type Filter Material...z—, .......Depth Filt; r Material...._. <br />Distance to nearest; ...Fdondation <br />_._............Property Line.........— <br />SEEPAGE PIT Depth ..Diameter...._.. Number. Rock -Filled- Yes No <br />Water Table Depth... <br />Size.. ............... ........... <br />Distance to nearest; Well... ...... Foundation....__....... _._.».....,Prop. <br />REPAIR ADDITION Prev, Sanitation Permit # ....... ....... ........ ........ ...... _Date ........... - --- - -------- <br />. ........ ..... <br />Septic Tank (Specify Requirements)_ ..... .. ............ .... .. <br />Disposal Field ',Specify Requirements). ........ <br />.......... .........►------------ <br />... .. ...... ....... ...... <br />(Draw existing and required addition on reverse Side) I <br />1 hereby certify that I have prepared this application and that the work will be done ln'Waccordoncie with Son Joaquin County <br />Ordinances, State tows, and Rules and Regulations of the Son Joaquin local Health District. Home owner or licensed regents <br />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 as <br />to become subject 100workman's Compensation laws of California." <br />Signed- ..........._...._Owner <br />......... ..... ....... 'Title- <br />Aeot4bler /than owner) <br />APPLICATION ACCEPTED BY <br />"'T <br />DIVISION OF LAND NUMBER.._...... <br />ADDITIONAL COMMENTS ............... <br />FOR DEPARTMENT USE ONLY <br />......................... ­ ............DATE S .. <br />, ".... <br />..................... DATE, <br />............ ........... .......... ___ ...... <br />....................... ........... .......... <br />Date <br />Final Inspection by .................. --f-, 4�.......... __ ............. <br />EH 13 24 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT f&S 21677 REV 7/76 3M <br />