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FO�ia 5,E . <br /> R OFFI ,0s'E.S I-, <br /> APPLICATION FOR SANITATION PERMIT 6­2 3 <br /> {Complete in Triplicate} Permit No, ....... <br /> ................. .......... .1 sem 7 <br />...... ................................................ ;I This Permit 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 /> escribed. This opooh tion ad in 'th unty Ordinance No. 549 and existing Rules and Regulations. <br /> ico ior_ o e w <br /> JOB AD 6CAT)CP .... . <br /> ---------_ ....................r ............ <br /> ENSUS TRACT .............. <br /> Owner's Nome t 1-7 <br /> 2--- <br /> ........ .-.,Phone . . .....I.............. <br /> Address ................. 3.7......_'.7f4..... --------- ------- City ...................---•------•---------------------- <br /> Contractor's Nome ST--­t4 <br /> ..........__.......... .......----..License Phone .59 6..:.hla_,0.7...... <br /> Installation will serve: Residence %Apartment House 0 Commercial E]Trailer Court 0 <br /> I I Motel [:]Other ........ ....... <br /> -------------------- ...... <br /> Number of living units:_./..... Number of bedrooms 3...___-Garbage Grinder --- Lot Size ............ .............. <br /> : I <br /> Water Supply. Public System and name ---------------- <br /> i ----•-----------------•-- - ....Private <br /> Character of soil to a depth of 3 feet. 1 Sand 0' Silt F1 Clay E] Peat E] Sandy Loam C] Clay Loam <br /> Hardpan E] Adobe Fill Material __ "... if yes, type <br /> ­ - ----------- - --- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings., etc. must be placed on reverseWdel <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is`vailabl ithin 200 feet,) i j3 <br /> ­7PACKAGE-TREATMENT SEPTIC TAN ... Liquid Depth ...... <br /> cop�cicit Type ... Moteriol.,O No.,_Compartrnie;;A;:ts—.1.....I ............. <br /> Distance to nearest.. Well ........_Foundation_6;0_1-:''.?�Prop. Line ... <br /> ----------­-- <br /> ............ <br /> LEACHING LINE No. of Lines L6ngth odeach I in-a 661 <br /> ,.-,-Toto Length <br /> -D' Box Type Filter Material ...I .Depth Filter Material erial ---.1'.---cf.......................... <br /> Distance to nearest: Well ..._,(0------ Foundation <br /> ............ Property Line ------ ................. <br /> _7 <br /> 1_�S�VAGE PIT --Depth --------- Diameter% JrX I- <br /> Rock Filled Yes No <br /> _,,,,:WaterTableDepth---- ff <br /> --_----------- <br /> --?., , <br /> Distance to nearest...W61f .,... ------------------....F6 6ndaton .... 0. Prop. Lin. f_-a----------L <br /> REPAIR/ADDITION.(Prev. <br /> Septic Tank fSpecify Requirements) ........ ..... ------- ........................­­.................. ...... ------­-------------------­-- <br /> Disposal Field (Specify Requirements) ------------- -------------- -------------- ......... ............... ................._......._...... <br /> ............. ................... . . .... ........__.. ....... ---------_-------------------- .........__............ . ..............L_................._1....... <br /> ... ....... <br /> . ........... ... ........ .r----------­-------------- -- <br /> ------------------------------------- ----------------------- ----- ------- ------------------------- <br /> {Draw <br /> raw existing and required addition on reverse side) <br /> I 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 Son Joaquin Local Health District. Home owner or licen. <br /> sed agents signature certifies thii following: <br /> "I certify that in the performance of the work for which thispermit 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 /> ---- ------------------------------------- <br /> By ... ........ .......... <br /> Title .. ..... <br /> (if other tho owner) <br /> PART ENT USE ONLY <br /> APPLICATION ACCEPTED BY'. ­77.......... .......... DATE ....... ---------- <br /> BUILDING PE`RMIT�ISSUED ..,..T7 'Op, DATE -------- ...................A <br /> ------------------------------------------------------- -------------- <br /> I <br /> ADDITIONAL-COMMENTS ................... ........ <br /> .................*............­,......­............................ ------------------------------ <br /> .................. ------------------------------------------------------------------- ............... ------ ............... ................1­­­........ <br /> ............................. Zt----------------- --------------- ........ .................. .............. ............. ................ <br /> ............................ -------- ...... . ............`.................. <br /> --------------__----------- ------------- -----------------Date -------a------------ <br /> Final Inspection by-. . ------------- -------------------------------------- --- -- ------ <br /> -SAN JOAQUIN LOCAL HEALTH DISTRI - <br /> E. H. 13 241.'68 Rev. SM 7179 3 V <br />