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FOR OFFICE USE: <br /> APPLI <br /> -- ----------- --- -- ------------I,--,-,,--,-------- CATION FOR SANITATION F . MIT <br /> ...................... ........................ (Complete in Triplicate) Permit No� <br /> =..57;2 <br /> ..... <br /> ............ i// <br /> .................. ............... This Permit Expires I Year From Date Issued ���Date Issued ...7-: <br /> Application is hereby made to the Son Joaqy'in Local Health District for a permit to construct and instS1@ions <br /> tbewWm*1jMherein <br /> described. This application is made in comp,liance with County,Ordinance No. 549 and existing Rule?Un-d RegulatS' <br /> : <br /> JOB ADDRESS/LOCATION <br /> ...... <br /> .. ...............CENS 'RACT -�,? <br /> Owner's Name <br /> Y---- -- <br /> ----------------------.----------- ---Phone <br /> Address ....S ..... .. . ....... <br /> ........ ........... ....... .......---------------------------------------- city S-7w.elm <br /> Contractor's Name ........................................ <br /> # / <br /> ------------------ ------------ ............License Phone <br /> Installation will serve: Residence 2�,� artment House 0 Commercial OTrailer Court ..... <br /> Motel E]Other <br /> Number of living units:... ...... Number of b6"drooms ---3-- <br /> ...Garbage Grinder -/x,.a-. Lot Size <br /> ............. <br /> Water Supply: Public System and name ..........4 ...... ----------- ...........------------------------------------------------------------------...Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt ED Clay ED Peat[I Sandy Loom-L] Clay Loom E] <br /> Hardpan El Adobe YFill M6teriol ------- ---- If yes, type .................... <br /> (Plot plan, showing size of lot, location of system in relation to s <br /> wells, building , etc. must be placed <br /> NEW INSTALLATION: ? ced on reverse side.) <br /> (No septic tank or seepage eepage pit permitted if Public sewer is available within 200 feet,} <br /> i - / <br /> PACKAGE TREATMENT SEPTIC TANK!L44--�- I:e ------1--.1 Liquid <br /> Depth <br /> Capacity Type P "r ...... <br /> T Material <br /> _� e 0. Compartments .-.Z---------- <br /> Distance to nearest: -z�..... ------------------Foundation -/a....... Prop. Line <br /> LEACHING LINE No. of Lines -------- Length of,each line....-7 / -------- Total Length ../,5'--0..... <br /> . ......... <br /> V Box Type Flitter Materid! l Depth Filter Ma <br /> I terial <br /> Distance to nearest: will ...... Foundation <br /> SEEPAGE PIT [4- i ------ ------------ Property Line ---37........... <br /> Depth Diameter I <br /> i ---i-- Number............. ...... Rock Filled Yes .2- No 0 <br /> Water Table Depth —� %- <br /> -------------------------- ..................Rbck Size/�O, <br /> /------ r--3-i----------------- <br /> Distance to nearest: Well .... --- --------------.-Fau'r1dation -..1..---........... Prop. Line ...A!7.----------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit#......1....................................... Date ------------- <br /> SepticTank {Specify <br /> ............*------ ------ --------------I--------------------- <br /> ........................... <br /> Disposal Field (Specify Requirements) ......... <br /> . ..................I............... <br /> ........... ----------- .......................................................n--------------....................... <br /> .... ........P <br /> ..--.........---........ <br /> "quired addition-n--o.n-reverse. -. .side) <br /> ."----•------- ------------...... .............................. <br /> (Draw exisfln�' an re---- ---------- <br /> I hereby certify that I have repared this aPplicition and that the work will be done in accordance with Son 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 ubject to Workman" Compensationlaws of California." <br /> Signed -- ------ <br /> ------ ----- ........................... Owner <br /> By <br /> �:.........................- Title ....... ............ .......... <br /> (If other than owner) ------------- ............. ...... <br /> FOR DEPARTMENT USE ONLY <br /> �APPLICATION ACCEPTED BY ... <br /> X----- -------------------------------- ----- --------------------------- DATE <br /> BUILDING PERMIT ISSUED ............ . ...... <br /> ADDITIONAL COMMENTS A'f <br /> - A.-- ----------------- ---DATE ............... <br /> ....... .......I-------------- ---- --- -t------------------------------ -----•--._..------------ <br /> /!.2 <br /> ----------------------.... -------- <br /> ... ........ <br /> ---------- 9.... ........... ............. Ar <br /> Final Inspection by: ..__ ------------------7---- -Z;:69------- <br /> .i---------- <br /> ....................................... .............Date ............ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b6 Rev. 5M <br />