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FPR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------M_..o.... -1 ------------- <br /> (Complete in Triplicate) Permit No.2.f:7:_/.,3._F <br /> -•-------------••------•----- - -- ........ ....... <br /> Date Is sued- <br /> .............. ................ .......... ........ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to-the Son Joaquin Local Health District for a permit to,construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 7, <br /> zooJOB ADDRESS/LOCATIOl'........ -C, ..................CENSUS TRACT_------ <br /> - ------ ------- - ----------- <br /> Owner's Name'..,.,.. . ...... P h o n e <br /> 7 <br /> Address--- <br /> City ----------- ---------Zip......------....-------------- <br /> Contractor's Name........ <br /> .......__. ..License #_,34,,_.0T1.._...Phone..-e11 ........... <br /> Installation will.serve: ResidenceX Apartment House E] Commercial ❑ Traile'r' Court El <br /> Motel Other......--- ----- ---- ------------­...... <br /> Number of living units:....-/------Number of beclrooms.;�T Garbage Grinder............Lot Size--- ............... -------- <br /> Water Supply.. Public System and name_..... --------------_- ---- ----------- .......................................... ------: --•.-Private <br /> Character of soil to a depth of 3 feet; Sand El Silt(-] Clay E] Peat E] Sandy Loam [3 Clay Loam E] <br /> Hardpan E) AdobeM ' Fill Material.. .... ....If yes, type..-.------:............. <br /> (Plot plan, showing size of lot, loc'a- tion of system in relation to wells, buildings, etc. must be placed on reverse side.) oil i <br /> NEW INSTALLATION; [No septic tank., or seepage pit permitted if public sewer is available within 200 feet,) � <br /> PACKAGE TREATMENT SEPTIC TANKSizei........___------------ -------------------- - ----- - .Liquid Depth------- --- ------ <br /> Capacity-_ ------- ---------Type....---...... Material------------------- _:..No. Compartments.----...:......------. --------- <br /> Distance to nearest: ......................... .....Foundation..._...... . Prop. Line-.------._..___-_------ ---- <br /> LEACHING LINE No. of Lines._:-------------------------Length of each line,_....... ---- --- Total Length L . ........... ...................... <br /> 'D' Box....- Type Filter Material------ ----- ...Depth Filter Material.--------------------------------------- <br /> Distance to nearest. Well................. ----------Foundation------------------------....Property Line._____....._...__............._.... . <br /> SEEPAGE PIT Depth.-..--,. .....Diameter---_-----------...Number------------- ----------I------- Rock Filled Yes E] No E] <br /> Water Table Depth......... ............ .............................Rock Size-----_......... ............................. <br /> Distance to nearest: Well............... .... ---------....---------Foundation--------------- - - Prop. Line ------ . ........ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------------------- -------------Date--------- ........ ................ <br /> Septic Tank (Specify Requirements)----...................... ------ .......... .......... <br /> ----- ------ ---- ------------------------- --- ----- <br /> Disposal Field (Specify Requirements)_...... ...... <br /> 41WI-10.161.......... <br /> ----------- .......... --------------------­--­ I- ----------------------------------------------------------------------- .........­ ---------------------------------- ...... ......... <br /> (Draw 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 County <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed agents <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 10 or man's Compensation laws of California." <br /> Signed---- .......... ......... ------ --.._.Owner <br /> By............................ ........................ A4!V -------- ------------------ <br /> .... ... ...Title..----- <br /> (If <br /> ..Title....... <br /> (If other than owner) <br /> N. FOR DEPARTMENT USE ONLY <br /> ------ ---- <br /> APPLICATION ACCEPTED BY.:, . ..................................... ............ ............ - -- ---- ...DATE..__��46.7771 <br /> DIVISIONOF LAND NUMBS ---.. .......................................................­­­.............. .........................DATE..................... <br /> ADDITIONALCOMMENTS..._... . ---- .... ..........._--------------------------------------------- ------------------- .... ...._ -_--------------------------------- - - . ......... <br /> ................................ .­_­.. ............. - ---------------------------­............... ................ ..... .. .....­................ ­ ­...............___ <br /> ------------­­-- ---- - .......................... .................................... -------------------------------------- ------------------------ --_--------------- ----------­­­........ <br /> ­ <br /> Final,Inspect-ion <br /> ----------_--------- ----- <br /> ---- -----------_-----------------------Date__ <br /> EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M <br />