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FOR OFFICE USE: APPLICATION FOR I—-SANITATION PERMIT <br /> Permit No. <br /> ................................................... low- V (Complete in Triplicate) <br /> ................................ <br /> Date Issued ................... <br /> This Permit Expires 1 Year From Date Issued <br />........................................................ <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described, This application is made in tom plianze�AC u y Ordinance No', 54icirim <br /> .,9 and existing Rules and Regulations: <br /> n 41 <br /> fr 5T ..010P.P.P.WCENSUS TRACT ................... <br /> JOB ADDRESSAOCATION ---- -- -- - ---------- . ........Onl .... .. -------- <br /> ..........Phone <br /> Owner's Name ... .... ...... ...... <br /> --------------- ...... <br /> -------------.............................. City ...... <br /> Address <br /> Contractor's Name -=—_-.License­*aV;V0r&_A__ Phone <br /> Installation will serve: Residence)K Apartment House-E] Commercial E]Trailer Court 0 <br /> Motel ri❑Other ... ---------__-----------­------- <br /> Number of living units ..... ...... Number of bedrooms ......._..._Garbage Grinder ............. Lot Size ......./.._:._... ..._..................... <br /> .... <br /> Water Supply: Public System and name . .............._......................._......I------ ............­....... .... ............... <br /> ........Private <br /> Character of soil to a.depth of 3 feet.: Sand 0 Silt 0 Cloy E] Peat[] Sandy Loam 56 -a'Clay Loom 0 <br /> Hardpan E] Adobe ❑ Fill Material ........... If yes, pe `'­. ...............•- <br /> (Plot plan, showing size of lot, location of system in relation to wells, building's,-etc., must be placed on reverse side.] <br /> � <br /> NEW INSTALLATION: - (No septic tank or seepage pit permitted if public sewer is available within200 feet,[ _J <br /> Size.5_#%11or.1dX_%�_r._ Licibid Depth ................ <br /> PACKAGE TREATMENT SEPTIC TANK I I J; <br /> Cope '00 No.. C8inpartments 4................... <br /> pacity1,;;�1e1:V.__., Ty ... Material.... ------ <br /> Distance to nearest: Well ................­----Founclotion;Va--- ...... Prop. Line <br /> bmgth of b'd Z h dine ft_e_- Total Length '........----•` <br /> . <br /> -LINE -------- <br /> No. of Lines! X <br /> ............�1 <br /> 'D' B6x Type' Depth Filter Mate0 <br /> ion le.-I------ - . <br /> Distance to nearest: Well _;/0__.V.._t_:n-=- Fovndat ....... Property Line ........... <br /> t__ Rock Filled Yes 0 Noik 0 <br /> SEEPAGE PIT Depth ............. Diameter --------- Number --- .......-.1...... <br /> Water Table D6pth ----------- -----------Rock Size ............ ........ <br /> ------------ <br /> Distance to nearest:.Well ................ .... -------Foundation ....... ........... Prop. Line .... .................I <br /> -----_------- <br /> fi <br /> ------------ Date ...............--__...---•-•-__--- <br /> I REPAIR/ADDITION JPrev. Sanitation Permit# ------------��,:--------- -- <br /> ........... I................... <br /> ........... .......................... ............ ...... <br /> Septic Tank (Specify Requirements) .......... ............ <br /> Icify Requirements) ---- ... . ................. <br /> Disposal Field (Spe ------------­ ............. ------- ......I.... .................... <br /> ► -------••-- .---.-_...1 ......................­•......_...I... --..... <br /> ------------ ............ ....... <br /> ...... ..........-1.................... .............. -------- <br /> ------------ ............. ----------- --------- ------ --------- <br /> .......... <br /> ...... _T-___-........ ..... <br /> (Draw.existing ati '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 /> , <br /> County Ordinances, State Lciwis, and Rules and Regulations of the Son Joaquin Local Health District.' Home owner Or licew <br /> I edonts signature,.certifies the following: <br /> ag fy <br /> .11 cert that in the performance of the work for which'this,permit is issued, I shall not employ Orson in such-manner <br /> as to become subject is Workman's Compensation laWs._of California." <br /> Signed .... ... .............. ......... ...... ...... Owner <br /> .......... ... <br /> Title ... ... ... ................... <br /> By .... ­----­ .................. ...................... ....... ------- ....... <br /> f1f other than owner) <br /> f <br /> FOR 'DEPARTMENT USE ONLY <br /> DATE <br /> L'-EA--T& ,�CCE TED BY ........................... TE .......................... <br /> APPLICATION ... ................................ ... ...... ........ <br /> ........................... <br /> ........... <br /> BUILDING PERMIT ISSUED .......... <br /> ADDITIONAL COMMENTSu..........._. ....... ------------I............ .. ........ ---------- ............. <br /> ............. <br /> ............... ------- ------ -- ------- ------------­------------ ......... ........ <br /> ----------f------------------- ........ ----,•---.........------------ <br /> ............... <br /> .................... ......... --- ..... ..... . ........ ----------------------- ................. <br /> I Final Inspection - -------- ......-1......­­........ ...............I——.......... <br /> I ---------- <br /> --- -------- -------------- ---------------------1----------- ---------- <br /> DISTRICT <br /> SAN JOAQUIN LOCAL HEALTH <br /> 7/72 34 <br />