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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT <br /> ............................................... .. -6i <br /> (Co 0 Permit No. _7,.e-_1............. <br /> (Corn Triplicate) <br /> .......... .............. ......I........ This Permit Expires I Year From Date Issued Date Issued _.7-Z-72y, <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work <br /> herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ,.-.. . <br /> CENSUS TRACT -................ <br /> Owner's Name ........ .... ... ...... . <br /> ...... ... ..)hdne c/ <br /> I Z.��.... ............ <br /> City <br /> Address .................... <br /> - ------ .... ......... ........License # 0? .. Phone <br /> Contractor's Name <br /> .......................... ....... <br /> Installation will serve: Residence Apartment House C] Commercial :[3Trailw Collu-r,\to <br /> Motel El Other ................................... <br /> ' <br /> Number of living units--t---- Number of bedrooms ....Garbage Grinder :o 7 ........... <br /> Water Supply. Public ' I <br /> System and nurne ................... <br /> ........................................ <br /> .............. .........Private E3 <br /> Character of soil to a depth of 3 fee!t� Sand 0 Silt C3 Clay C] A Sandy Loom 0 Clay Loom 0 <br /> Hardpan C] Adobe C] Fill type ---------_----- <br /> (Plot plan, showing size.of lot, location of I. systemzint,lrelatib*h"�t6Lwells, builclings`:'�"eftc, must be placed ant reverse side.) <br /> .., --V .4 A " I J <br /> NEW INSTALLATION: JNo septic,tank or seepage pit permitted if i <br /> �p6blic sewer s available within 200 feet,) <br /> PACKAGE TREATMENT I SEPTIC TANK W10"U4..Size-------... ---------------- Liquid Depth <br /> .............. ......................... <br /> Capacity T <br /> ................... Type ................$f�t_-M6teeiql _ No. Compartments:. ..•---•---.-......... <br /> Distance to nearest: Well ------ .............................Foundati9p <br /> P.:.;:�.............._. Prop. Line ........................— <br /> LEACHING LINE No. of Lines ------------------------ Length of each line.__.....__.__---------L_. Total Length ... ................ 00: <br /> 'D' Box i...... Type Filter Material ......:.............Depth FilterMaterial .__...__.--•....... ......_...,_........:... <br /> Distance ti nearest- Well ........................ Foundation ....._..---.i_._.._..... Property Line ........ ............... <br /> SEEPAGE PIT Depth __,Diameter___,•...........:.­Nurnber__ --------------I---- <br /> Rock Filled Yes 0 No C11E <br /> 't- <br /> Water Table Depth ....................... .............Rock Size A........... ............... <br /> Distance tlearest: Well ..................... .......I...........Fovn' dation !.............. .... Prop. Line ................... <br /> REPAIR/ADDITION(Prev. Son Italian:-Permit ...................... ..... Date . ...........0 <br /> �# <br /> 71, .........10 <br /> Septic Tank (Specify Requirement- <br /> -------- PJ <br /> Disposal Field (Specify Requirements) ......�k ........... <br /> --------------------- ----------------------- ----­--------­---- ....... <br /> ............... i JA <br /> ----------------------•---._.......-----.. ­------- ----- <br /> _----- ------- ............. <br /> �& 1�-------- ...............1............)........................ <br /> -----------------­­..................... ............ .......................... --------- ........................ ........ -------------------- <br /> 1(f Draw existing and required addition on reverse side) ----------------- ------- <br /> I hereby certify that I have prepared this application and thlat the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations otf the San Joaquin Local Health District' Horne owner or licen- <br /> sed agents signature certifies the following: <br /> t <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 /> B y <br /> y ----- ..... . ....... ........... ...................... <br /> --- ---- --- ....... --- <br /> . ........... <br /> (If oth t n owner) N ... .... <br /> FOR DEPART USE-IONLY <br /> APPLICATION ACCEPTED 11Y, ......................... DATE ......7,5�.. <br /> BUILDINGPERMIT ISSUED .......................................................... ................. ..............................DATE ............................... ......... <br /> ADDITIONAL COMMENTS .......... ..................... <br /> .......................................................m...............­......................................... <br /> ------------------------------------------------------ ..................... <br /> ............................................................ ........... •.................. ........... ........................... ....................... ...................... <br /> -------------­-------------- .. ....... <br /> 4 _�nl............. <br /> .......... <br /> Final Inspection <br /> ..Date ................. <br /> SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> E. H.13 24 1.'68 Rev. 5M. 7 171 'A AX <br />