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FOR OFFICE USE: 0--2- ( <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No. <br /> .......... .............................. . <br />. <br /> ......................................................... This Pernift gxplr#s I Year From Date Issu I Issued......Z............. <br /> Application is hereby mods to the Son Joaquin Local Health District for a permit to construct an nstall the work heroin <br /> described. This applica ion is made in compliance with County Ordinance No. 549 and existing Rules and Regulations- <br /> CENSUS TRACT .......•................. <br /> JOB ADDRESS/LOCATION <br /> ... ... ............. ................. <br /> Owner's Nome ........... ........................ Phone ... ......... <br /> Address . . ..... ......... City..........._........ ........ .. .... ...r <br /> Contractor's Nome ------- .......... ::.......License # <br /> Installation will serve: Residence 2TA'partment House 0 Commercial OTraller Court C) <br /> Motel0 Other .-.-----••-•.....­*.............­....... <br /> .1 <br /> Number of living units:.... ..... Number of bedrooms ....A....Garbage Grinder ............ Lot Size .................................. <br /> Water Supply: Public System and name -,.............__...........................................................................................Private ❑ <br /> Character of soil toa depth of 3feet. SandO Silto Clayo Peat(:] Sandy Loam o Clay Loam o <br /> Hardpan WI-l"Adobe-0 Fill M4terlal ........ If yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. -must be plo'ced on reverse side.) <br /> NEW INSTALLATION: JNo septic tank or seepage pit permitted if public sewer is.available within 2004eetJ <br /> PACKAGE TREATMENT SEPTIC TANK fof' Size "Z'7 ............ Liquid Depth ................ <br /> Capacity ,' Type Moteriol....!� ._ --- _- No. Compartments .......... <br /> Distance est. Well ..._....,5.,,//.............Foundation Prop. Line <br /> LEACHING LIN.ENo. of Lines .......1�.............. Length of each line.. ......... Total Length ..1,2,401-.1............ <br /> Box ... Type filter Material ......5.&......Depth Filter Material ....../f................................ <br /> Distance to nearest: Well ........ Foundation ....... Property Line ... ........... <br /> SEEPAGE PIT Depth .... Diameter ----ls._.". Number .........0............. Rock Filled Yes 0No 0 <br /> Water Table Depth ..... --------- ................Rock Size ...-l./ .i. ,3 -- p II <br /> Distance to nearest- Well ....... ................Foundation ..... Prop. Line ..... ..... . <br /> R EPAIR/ADDITION{Prev, Sanitation Permit# ------------- -----_---------------------- Date ........................ ....... <br /> 0 <br /> Septic Tank (Specify Requirementsj._............... ............................ .............................................................................. ............. <br /> Disposal Field IS pecify Requirements) .......... ....................... .................................................. ................................... <br /> ---------------------------­-- ----------I--­--------­--- ----- <br /> -- ­ ......................-.-.-.-.....--.-.-..-.-.---.-.-.-.,.-.-.-." <br /> {Draw existing and required addition on reverse.-s-.'.l,.d-.-.e.- <br /> .'I.............I......................... <br /> ---*................................................*........ <br /> I hereby certify that I have prepared this application and that the work will be don* In accordance with Son Joaqu <br /> County Ordinances, State Laws, and Rules and Regulations of the Sort Joaquin Local Hoafth,011strict. Nome owner or licew <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 /> ---------- <br /> ................ ------------------- <br /> ----------- ...... litle _q <br /> By -------- --------_----------- <br /> (if other than owner) C> <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... <br /> DATE <br /> ..-. <br /> . . .---- - ------ - ... ------,....... <br /> .BUILDING PERMIT ISSUED ------ ............. ...DATE .. ­........ ..................ADDITIONAL COMMENTS .--- ­ ..................... ........................I...... . ......w­..................... <br /> ------------ ------ ....................................... ...................... -------------- -------•----..........._..----•----.....------......................................... ...........- <br /> ---------- - --- ­ -----------­-------• ....... ................... <br /> ........................................ --------- ­-­­---------------- ­-------------6................................... <br /> -------------------------- ------- . . .......1_1­1---------------------------------------- .............. ............................. ............ <br /> FinalInspection ------------------ -----------------••---.---•-----•--- ...............................Date 4177 <br /> EH 13 2b 1-68 R%ev!� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />