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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ............................... ermit No, <br /> P .......... ........ <br /> (Complete in Triplicate) <br /> ..............1*1­1................ .......... <br /> ............. ......_­­..................... This Permit Expires I Year From Date Issued <br /> Date'Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit <br /> mit to I 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 /> _C? /2d- <br /> .............. ........ <br /> JOB ADDRESS/LOCATION TRACT <br /> �*3&r��..IrT <br /> Owner's Nome ..................................... ......... . .........Phon <br /> Alf ...... Ci <br /> . ....................... .......... ...................... ......... <br /> Address ...... ............. <br /> Contractor's NomecA�..� ........ .............Lice n s e #30-5 t...... ...... Phone, <br /> r <br /> Installation will serve.. Residence 2Kpartment House 0 Commercial OTrailer Court <br /> Motel 0 Other <br /> Number of living units:............ Number of. bedrooms ...Garbage Grinder ............ Lot Size ...... .............. ................ <br /> Water Supply: Public System and name ... ---------------------------------------------------- I....Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt E] Clay ❑ Peat 0 Sandy Loam y cloy Loam 0 <br /> Hardpan C] jAclobe-o-,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 tide.) <br /> NEW INSTALLATION: (No septic'tank or seepage pit permitted if public sewer lis available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size................................................ Liquid Depth .......................... <br /> Capacity .............. Type .................... Material...................... No. Compartments .......................... <br /> Distance to nearest: Well ....................I.................f oumdation........................ Prop. Line .............:.......6- <br /> 17- ne---•.............. <br /> .LEACHING LINE I No. of Lines ..............:......... :Length of ioch II' ......... Total 'Length I .......................... <br /> V Box ....I ....r .........k�" -Fiiter ............................"­ <br /> ........ Type Material ....Depth Im <br /> Distance to nearest- Well :...:n . ....... ..... Foundation ........................ Property Line ......... <br /> SEEPAGE PIT "Depth .............Didmeter ............. Number ............ ............... Rock Filled . Yes (3 No 0� <br /> Water Table :Depth ....­­...............................I........Rock Size .........-••-•••-•--.------•-- <br /> i Distance <br /> ...........7....... --------- <br /> Distance to I nearest: Well ...........:...•____--_..._. ..._Foundation ................... Prop. Line ................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit* ...............I................... .... Dote ..................................) G <br /> Septic Tank (Specify Requirements) .................... ............ ...................................... ............ ............. ............. <br /> ........... <br /> Disposal Field (Specify Requirements) -------- ....... <br /> ..-----+:.---------11d ....----------------------------- ------------------------- <br /> .................. ...... .............. <br /> ........................................... ....................................I-------------­.......I..................... .......... ........ -----•-----....._.__................--. <br /> (Draw existing and required addition ori reverse side) <br /> I hereby certify that I have prepared this application and that the workwillbe done in accordance With Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son -Joaquin'Local.Health District. Nome owner or licew <br /> sed agents signature certifies the following: <br /> "I certify that in' <br /> the performance of the workfor 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 /> By .......................... .Tylb......... .04 <br /> ----------- ........... ........ <br /> an owner): <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ........... ----------I.........I.................................. ........... <br /> DATE !F.' .......... <br /> BUILDINGPERMIT ISSUED ....................................... ...........................I..... ............................DATE ........_...::.....:......_........---•-•.• <br /> ADDITIONALCOMMENTS ....................................................................................................................... ............ -_------------ ......... <br /> ---------------------------- -------------------------- <br /> ---------------------------------*.......*,*",* ....... ........................................I'll------------ <br /> .......... <br /> .............. ............ ......... ................. ............­..............­--------- ..................... ..... ............. ..... <br /> ----------------------••---- e; ..................—..................---:•....I.._...............--•--•. <br /> l <br /> Final Inspection by. ................. 1 ....Date ..........e <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 13 24 7/723-A <br />