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FOR OFFICE USE: t7: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> Icomplate3ft Triplicate) <br /> .......................................... Date Issued <br /> ................ This Permit Expirek i:,Year From Onto Issued <br /> .................... <br /> Application is hereby,made to the Son Joaquin Local Health bistrict for 0 permit to construct and install the work herein <br /> descfIbed.This application is made In compliance with County 02inaor= No. 549 and oxisting Rules and RegWOHMM <br /> JOB ADDRESS/LOCATION M _-------------CENSUS TRACT .......................... <br /> Owner's Name ...... . ir- <br /> ................................................. ......Phone ­-.1............. ................ <br /> . q. <br /> :�7 Z- 40 <br /> Address ............../1-F,4,.,AF...... .......— city ......... ....... .... ........................... ................ <br /> Nome J05'..-J". —License# __T.P—Phone .............................. <br /> tahtractar's Norn <br /> Installation will serve: Rii-sidence r]Apartment House IJ Commercial OTrailer Court 0 <br /> Motel 0 Other,,....OWS;_ <br /> ............. <br /> Number of-living unitst...J.,_ Number of bedroorns ............ to?Size ------ .... ....... <br /> Water Supply. Public System and name .... ..................................... ........................-_--__-......_.....----._.._.__.._...Private <br /> Character of soil to a depthof 3 feet. Sand 0 ,Silt[3 Clay 0 Peat 0' ,Sandy Loom 0 'Clay toom 0 <br /> Hardpan[9' Adobe 0 Fill M.6terial if yes,type............................ <br /> (Plot plan, showing size of lot, location of system: in relation to wells, buildings, et;L must be placed on reverse side.) <br /> NEW INSTALLATION, (No septic lank or seeppge pit permitted if public seweLMovallable within 200-leetJ <br /> PACKAGE TREATMENT I I SEPTIC TANK J)f sizo,q- <br /> pquid . . <br /> . ....... . <br /> Depth <br /> capocit' .1,P�.P ..... Type Material. .... No. 'Compartments ._.C9 <br /> Distance to nearest. Well Prop. Line__5.. ....�....... <br /> LEACHING LINENo. of lines Length of.each one....... Total tength. r........ <br /> Box Typq Filter Material ......!$.,k__Depth Filter Material ...................;......... <br /> Property Line <br /> Distance to nearest- Well ...... Foundation ...... '4fl.7.........0 <br /> SEEPAGE PIT Depth Diameter Number Rock Filled Yes 2k !q0 C) ID <br /> V. <br /> .. <br /> Water Table Depth ...............2,Z/......... .........Rork Size <br /> Distance to nearests Well __ ......./A-��,/.407._.Founclation' Prap- Line ..... <br /> REPAIR/ADDITION(Prev. Sanitation Permit 5P <br /> ......... ---_----_-_---------_ -Date ................................. <br /> SepticTank (Specify Requirements) ... ........................................ ....................................__...................................................... <br /> Disposal Field (Specify Requirements) ............................... ...................... .................. ..................._.r............. <br /> .............................................­*1........... .........._.—-----•-­--,...----------•--... ------....... <br /> .......................*....................................*..........................*.........­*--------------------*...................I......I....... ............I...... <br /> (Draw existing and required addition on reverse side) I <br /> I hereby certify that I have prepared this application and that the work %AH be d*rA In =*Mance with Son Jftquln <br /> County Ordiminces, State Laws, and Rules acid Regulations of the Son h"VIR tomf Hisaftli'Distrid.memo owfw or.11cm <br /> led agents signatura certifies the fanowing: I f <br /> "I certify that In the performance of the work for which this permit is losuW,I :hail not employ ony per""in such mamer <br /> as to become subject to WorkmaWs Compensation laws of Wifetulm" <br /> Signed ................................... .... Owner�z............... <br /> BY ..............................*(........ ....................'I'.............. <br /> Ilf other than owner) <br /> MR DEPARTMENT USE ONLY <br /> ..................... <br /> APPLICATION ACCEPTED BY _ DATE <br /> - ------ .. <br /> .......... <br /> BUILDING PERMIT MUED ............... . ...... ..... . .......... ............. .........................-.—DATE ....... ................................ <br /> ADDITIONAL COMMENTS .......... ..... .............................__....... ....................­11....................... ....... ....... <br /> .......... <br /> ------- ---- ---------------- ....... ..................... .............................................. .......:�.............. <br /> ..........�:............................•--•--- _•-.__......_........_................._...... %1............ ..... ... . ............ ...... <br /> ........ ................. ... -------------- <br /> -- ---I-------- <br /> ­­­... .... .... <br /> Final lnspettion by <br /> . ...................................—.....................................................owe ......... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • E.H.13 24 1 Rev—SM <br />