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FOR OFFICE US <br />........i- ...... APPLICATION FOR SANITATION PERMIT <br /> .............. ............. <br />...... ...............�-:.......... (Complete 1A Triplicate) <br />...... ................................................ This Permit.EX'pWos f-y -ear�­Fiom Date Issued Dote Issued <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 mode In compliance with County Ordinance No. 549 and existing Rules and Regulations.. <br /> JOB ADDRESS/LOCATION <br /> ...............................CENSUS TRACT .................. <br /> Owner's Name <br /> f. <br /> .......... ....... <br /> .......Phone ....................... <br /> ........................ ................ ............. ............. <br /> city <br /> Addres's .........*- Z <br /> ,0 <br /> .......................... .......... <br /> 000 <br /> r <br /> Confractor's'Name ...... <br /> .." 'Oo <br /> ...................... ...........L icen so # Ph'one <br /> lnst�ol lotion.-,kil I serve.. Res idence)g A pa rtm ent House <br /> ;Commercial ]TrailerCourt ❑ <br /> Motel E]Othw <br /> Nuner of living units:.... ... Number of bedrooms -----Garb4q'g'e Grinder Lot Size <br /> 01 ... .............. <br /> Watee Supply:-:Public System and name ......_............. <br /> .................. P <br /> riv <br /> ate <br /> . <br /> . .....-------- ........................... ...... ....... <br /> Cho cter of soil to a depth <br /> of Veet.- Sand El Silt 0 Clay El "Peat❑ Sandy Loam ❑ Cloy Loam 0 <br /> Hardpan E] Adobeg Fill Material ---------- If yes,type ....................... <br /> {Plot,plan, �3`howing size of lot, location of system in relation torW ' <br /> ells, buildings-,,etc, must::be placed on reverse side. <br /> NEW INSTALLATION: {No I septic tank- or,seepage pit permitted If publk sewer-is available within 200 feet,( <br /> PACKAGE TREATMENT ( J I ��_ <br /> SEPTIC TALK f Size................................ Liquid:Depth .......................... <br /> .............. <br /> Capacity ... .......... . Type ...... .. <br /> . .......�.. Material........................NNo. Co :m p' <br /> . . ortments .......I.............. <br /> Distance. to nearest- Well ................................Foundation ..... <br /> .�—Prop. Line ...................... <br /> LEACHING LINE No. of Lines ------_------_------ Length of each line.----- <br /> .......... ......... Total Length ....................I....... <br /> V Box .........._ Type Filter Material ....................Depth Filter Motirial ............. <br /> .......................... <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line <br /> . ....................... <br /> SEE.PAGE PIT Depth ---------- Ditimeter ................. Number ............. .............. Rock Filled Yes ❑ No <br /> Water Table Depth ................ .............. ....... <br /> . . .. . ..........Rock Size ......................... <br /> Distance to nearest. Well ........................................Foundation -------------_---N Prop Line ...... ............... <br /> REPAIR/ADDITION.iPrev. Sanitati6n'Permit# ...................... ................... Date !- <br /> Septic Tank (Sp6cify Requirements) ........................... <br /> X Z ............ <br /> ------------------------ --------- ... <br /> .... <br /> Disposal Field (Specify Requirements) <br /> .......... ................................... <br /> ----------- .................................................. .......... ...................... <br /> ...............1­............. ...............................p_....-----•-- I.__...--- ....... ......................... ......................... ............. ......... <br /> (Draw existing and required addition on reverse side) ......... <br /> 1 hereby certify that I have prepared this applicaiian and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San' 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 Jn such manner <br /> ts'to become subject to Workman's Compensation laws of California." <br /> Signed'.------------I........ ... ... Owner <br /> .............. <br /> By .._.....-_fir............... .. <br /> ....... .............I............... Title <br /> .............. <br /> {Ifo an owner) ........................... <br /> FQR PEPARTMENT USE ONLY <br /> ...............I...... <br /> BUILDING PERMIT ISSUED __................... ...... .. ........ ......... DATE ....... ........ <br /> APPLICATION ACCEPTED. BY ... <br /> ..... DATE ...........................•-•......... <br /> ADDITIONAL COMMENTS ....................................•------•- <br /> ............................................................... ..........................I..........I....................... <br /> .............. ............. <br /> -------•................. <br /> ........................ . . -•----• -....•--•--......•------. ....................I........................................­..I...................... ...Final Inspection by: .......... 6a.t.e......Q. ................................. <br /> SAN JOA UIN LOCALHEALTH DISTRICT .. <br /> ......I.................................­..........I...................... <br /> ............ ...... <br /> E. H. 1324 I-'6a Rev. 5M <br /> 7/72 3 M <br />