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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------- <br /> A 77- <br /> ........ ......... .......... (Complete in Triplicate$ Permit Na .... ........ <br /> .......... .......... <br /> tDate issued ... <br /> ...... .......I............ .......... This Permit Expires ] Year From Dot*Issse <br /> ued <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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/L0CATION_..,/_3_4?,5. .....4`1.....ca • C <br /> 14, ..........��_r__CENSUS TRACT .1.........­....... <br /> Owner's Name <br /> e ......... <br /> ........................ ........ ............Phone , 77.- 7 <br /> ► <br /> Address s -0 <br /> . 71- .. .... <br /> ............ ..............w City .......s5_7 ............ <br /> L , .1-........... <br /> Contractor's Name --------= 42 ................>.......License # ....._................. Phone ...---•-••••-••---....... <br /> ........... <br /> Installation will serve:. Residence[Apartment House 0 Commercial)]Trailer Court C] <br /> YN-p - <br /> Motel El Other......... `•• <br /> •••.......----- <br /> Number <br /> ......*------- <br /> Number of living units---_i------ Number of bedrooms _,_.Garbage Grinder ..... ...... Lot Size ...... !�'?......... <br /> Water Supply. Public System and name ..................... ...... . <br /> . ...........-.........._­................................................Private <br /> Character of soil to a depth of 3 feet.. Sand E] Siltt Clay 0.0 peat 0 Sandy Loom 0 Clay Loom 0 <br /> Hardpan 0 Adobe- _fill-M6terlol ......... If yes,type ............... ............ <br /> (Plot Plan, showing size of lot, location of system in relation4t,a wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer-is-available within 200 feet) <br /> PACKAGE TREATMENT SEPTIC TANK el-I ....... Liquid Depth ........fi/I*......... <br /> Capacity;?4Z/_Type Y%e M;Ie-Mciterial.- ORV4�4P2.giMNo.-��,.Comportments .........7`_ <br /> Distance.to nearest.• Well ------ -_1j90 <br /> ...... ... Foundation....... <br /> Prop. Line _14?49..... <br /> LEACHI <br /> NG LINE No. of Lines ......-T------------- Length of each line'..-..........8 ­ <br /> ... ---- Total Length <br /> 'D' Box .Y4-4_. Type Filter Material ... ........Depth Filter Material ............ ..................... <br /> Distance to nearest: Well ..... r......_. Foundation ..... Prop" Line ..../474!..`..... <br /> SEEPAGE PIT Depth ...Z.s,•.'....... Diameter Number -------?-�-----_----_ Rock Filled Yes No <br /> Water Table Depth ..............1.P.O. <br /> ------- ------- ...Rock Size .........Z,.�L..... <br /> Distance to nearest. Well ....... <br /> =. --:...Foundation ....... Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .................I---------t .......... Date ................. .......... <br /> Septic Tank (Specify Requirements) ---------- ............... .............. <br /> ................. ..................•--•-- <br /> -........... .................... <br /> Disposal Field (Specify Requirements) ' .'':.-_-_. T4 <br /> ............ <br /> . .......... ...... ........ ............................................. <br /> ------------ <br /> -------------- ------ <br /> --------------------- <br /> ------------•-------------------------------------------------------­­­---------------4.............. <br /> (Draw existing and required addition on reverse side) ---..-•----••...................•--.... <br /> ----------*........................... <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 Joacitiln Local Health,,District. Home owner or 11cen- <br /> sed signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued,-1 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 .... -----------------------------------------------*­ Title __............: <br /> -------------------------------------------------------------------- <br /> (if other than owner) <br /> DEP TMENT USE )ONLY <br /> APPLICATION ACCEPTED BY _ <br /> ....... DAT,,E <br /> 6UAbIR6 'PtOKif-flsSt)tU ------ TE <br /> nAT <br /> TS' . ....... -- ------ ------------------DA <br /> . ..... -- ---- <br /> ADDITIC)"AL COM NI <br /> Al� T, ------•....----- <br /> --------- <br /> ----------------- ------------------------------------------------ ------------ <br /> • <br /> . . ........ ------- - -- ----------- ..........I-------- -------­­_­.................1­................. <br /> .................... --- ------ ..... - ---- ------ --­----­----­----------- <br /> ......................... <br /> -------------------_-------- --- ---- ---- - <br /> ------ ----------_-----------------_- ------ .......................... <br /> .................. -..-.--......................... ....Final Inspection by: --•..............Dote ... <br /> ------------------- <br /> EH 13 2h 1-68 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />