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FOR OFFICE USE: 11 — — <br /> - ----- ---- <br /> --------------------------------------------------- APPLICATION FOR SANITATION PERMIT <br /> -------- =----------------------------------------------- I(Complete in Triplicate) Permit No.. <br /> Ej <br /> ---------------- This Permit Expires 1,Year From-Date Issued Date Issued <br /> A-_- <br /> )plication is hereby made to the Son Joaquin Local Health District `fo�r 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 /> "-Al r7 , <br /> JOB ADDRESS LOCATION --------------- <br /> AM <br /> , il `­- -----------__CENSUS TRACT <br /> Owner's Name -----;4V_V/__777 <br /> Address {--- ----------------Phone <br /> ----------------- ---------------------- -------- city <br /> --------------------------------- <br /> Contractor's Name <br /> ---.LicensePhone <br /> --------- <br /> Installation W'-ill--serve: -Reside <br /> nceEl A artm&nt-House,E] Corn,mercial [71Trailer Court <br /> Motel 0 Other <br /> Number of living units:__!777:_ ----------------- <br /> Water Supply: Number of bedrooms ---- <br /> _----_---"Garbage_Grinder Lot Size <br /> ,Cublic SYstem-and'name`': ........... <br /> _AW -------- 11 e <br /> -.I--- -__­.___�­A,--------�!�7--------------- <br /> Character of soil to a depth of 3 feet, Sancl'[] Silt I -t-- ------Z-------------------------------------Private <br /> P Clay El Peat E] Sandy Loam -F] Clay,Loam <br /> Hardpan [Ell Adobe, <br /> :k Fill Material --- If yes, type ---------------------------- <br /> (Plot plan, showing size oot, <br /> i f llocation of system i! relation to wells; buildings, etc. must b <br /> NEW INSTALL e placed on reverse side.) _!4 <br /> !En TIO (No septic tank or seepage pi permitted if p6blic sewer is available within 200" <br /> feet,)�A <br /> PACKAGE TREATMENT SEPTIC TANK feet) <br /> Capacitye-gif�,'0-0-494Type Size- -------- ------ Liquid Depth- _:-- ------------ ---------- <br /> aterjale:!F��O"­No. Compartments <br /> Distance to nearest. Well ---------------------Foundation ---/Q_'-_-_------- - <br /> -,"'LEACHING LINE No. of Lines Prop. Line _-, _- ' -0 <br /> ------------ <br /> ---------------- Length of each line---_7��' A <br /> 'D' Box 1,iF-5 Type Filter Material 'S, ----------- <br /> ----- ----- Total Length <br /> Depth Filter'Material if <br /> --/If---------------------­----I ry Distance ------ <br /> to nearest. Well ___ <br /> ----------- Foundation • <br /> SEEPAGE PIT b�'e'v' Depth -Property-Line A��.------------- <br /> -- ---------- Diameter 1�37 <br /> --- ------- Number --- <br /> 7 -------;R ------------- Rock Filled Yes R1 No <br /> CI <br /> Water Table Depth -----�700-1-----------------------------Rock Size I�6 /r <br /> Distance to nearest: Well /� I*- ­ - -------- <br /> S-e,>--------------------Foundation --le----- Prop. Line J_ <br /> REPAIR/ADDITION(Prev. Sanitation(Permit# -------- <br /> i � ' -----------------1�-------------------------- Date <br /> Septic Tank (Specify Requirements) -------- ------ <br /> Disposal Field (Specify Requirements) ---------------------- --------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------i . - ----------------------------------------------------------- -----------------------------------------I--------------- <br /> ---------------------- ------------------------- I--------------------------------- ------------------------------------------------------------------------------------------------- ------------ <br /> ------------------------------- - <br /> ------------------------------------------------------------------- ---------- <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 San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> of the work fc which <br /> "I certify that in the performance lch I <br /> as to' )r his permit is issued, I shall not employ any person in such manner <br /> become subject to Workman's Compensation laws " <br /> Signed ----- ---- C_�I of California." <br /> -------------- ----16--------------- ----------- - --- ----------­ I <br /> --------------- Owner <br /> By - ------------------ V - <br /> (If other------------ -- - ---------- - - ----------------- -Title than ow/)� A- _Ij I <br /> APPLICATION ACCEPTED 13Y _Z_ V 11,C FOR DEPARTMENT USE ONLY <br /> --------- - ------------------ -----II------------------ 7 <br /> BUILDING PERMIT ISSUED - --------------- -- ri )ATE <br /> ADDITIONAL COMMENTS ----- - --------- ----------------------------- ------------------- <br /> _-DATE <br /> ------------------------------------- ----w� _ _ __ __ ___- --------------------------------- <br /> ---------- --------------------- --46- 2__?�-.,?-2---- <br /> --- ------ - 1� �,i� ----- <br /> ------------------------------- ------------ --- ---------- --------------------------------- ---------------------- <br /> ------ ----------------------- <br /> -------- ------ ------- --------- ------------------------------------------------------- --------------------- ---------------- <br /> Final Inspection by: - , <br /> --------------- --------------------- ------------- <br /> -------------------------------------------- <br /> ---------- <br /> ----------------------------------------------Date <br /> SAN A UIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M, <br />