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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ............................ ................. Permit No. ...7 <br /> .................. <br /> ­lComplete In Triplicate) <br />.........................................•-•---•._....... . <br /> Date Issued ./::.�........ . <br /> .................................. ......... This Permit Expires I Year from Onto Issued <br /> Application is hereby made to the Son Joaquin Local.Health District for a e, to construct an� Install the work herein <br /> f ' mit <br /> described. This application is made in compliancewith Cou y r nance permit <br /> 549 and existing Rules and Regulations- <br /> I I 'ou I <br /> . C <br /> JOB ADDRESS/LOCATION ................................... ... .. ...4 ..... .......XENsus TRAcr ._.. - <br /> ........... <br /> Owner's Name --- <br /> ... ..... .. i. . .....•. ...... ..................... ........................... ....Flione ......------...........---.....---- <br /> S <br /> .......... .................... <br /> Address ..............-.....-----•• city ------------ <br /> ---------- - - d-�_ _-�_ <br /> ----- .......................License Phone EankXZ� <br /> Contractor's Name ------- <br /> J... <br /> Installation will serve: Residence QAparfm—ent House 0 Conimerdal OTraller Court 0' <br /> Motel 0 Other............. ............**............ <br /> Number of living units:---------- Number of "ams Grincler,./_45?-%. Lot Site ---------------------------------- <br /> Water Supply. Public System and name ---4_• ...................... M...............Private 0. <br /> Character of soil toa depth of 3 feet: Sandr] Silto Clay -0 Peato- - Sandy foam o Clay Loarn 0 <br /> Hardpan 0 Adobe d1Material If yes,typo............... ............. <br /> (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted If public sewer is available with In 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK{ Size.._---- ................ ........... Liquid Depth �.................... <br /> Capacity --..I............... Type .................... Material...................... No. Compartments ............ ........ .. <br /> Distance. to nearest. Well ....................................Foundation .................. Prop. Line ........................ty <br /> LEACHING LINE No. of Lines ........ -------- ...... Length of each line........................:... Total, Length ............. ........... <br /> N <br /> V Box ............ Type Filter Material ....................Depth Filter Material <br /> ----------- <br /> Distance to nearest: Well ....4---............ Foundation -------------------_-- Prop" Line ........................ . <br /> SEEPAGE PIT [ I Depth .............. Diameter ---------------- Number -------------------­------ Rock Filled Yes 0 No 0 <br /> ........................... <br /> Water Table Depth ...___.....................................Rock Size ...... <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line .... ................. <br /> REPAIR/ADDITIONIPrev. Sanitation Permit# .................7�............. ............ Date ...4....... ................... <br /> Septic Tank {Specify Requirements).------------------------------------ ---- ---­-­-- ............. ....... ......... .._......__...__.-•......... <br /> DISROyal Field (Specify RecpArements) ........... .......... ................. ......... <br /> .............. .............. ........ ---------- <br /> y-------- ---- ------------------------- -(Draw existing and required addition on reverse side) <br /> I herebcertify that I have prepared this application and that the work w.Ill be done In accalrdance with San 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 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 <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------- Owner <br /> ,0)--------------- <br /> By .............. ----------- ----- - • ........... Title ZV -------- e ----- -(:2 ........... <br /> (if other owner) <br /> FOR DEPARTMENT USIE ONLY ii <br /> APPLICATION ACCEPTED BY ------- ....... - --- - -- -------- DATE:....--- . .... .. ------- <br /> BUILDING - <br /> BUILDING PERMIT ISSUED .--' S� � . _ . ..DATE -------- ..................... <br /> ---------------- ------ -----------­---------*........... ............*...........*-------------- <br /> ADDITIONALCOMMENTS --------------- -----------.................. -----........................... ---------­----------- ................... ....... <br /> ................................ ...............I-------- ......................... ........... --------- <br /> ................................. ..............-1...... .............. <br /> .......... .... ......................................................... ......­....... .......... <br /> ...................... .... ------ - ............­­---- ..........­­­­...... ........... -------------/1 7 ............. <br /> Final Inspection -------------- - .......... ....................................:................Date .... <br /> .............. ........ <br /> EH 13 24 1-68 Rev. 5M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />