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FOR OFFICE USE- <br />................... <br />... . ....... ........... I .... i� ...... . 1. ­... <br />APPLICATION FOR SANITATION PERM17 <br />(Complete In Triplicate) <br />This Permit Expires 1 Year From Date Issued <br />FOR OFFICE USE - <br />Permit No. <br />Dote lssued..i07?'",77 <br />Application is hereby made to the Son Joaquin Local Health Pistrict for a permit to construct and install the work herein described. <br />This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br />JOB ADDRE!5S/LOCATI()N..al,*.4.4P-5. ........ ..........._CENSUS TRAa,______­ ......... <br />Owner's Name._...._ ......... .... Phone .................. <br />Address .................. IaOZ -5 ...... city. . ................ ...... <br />License Phonis..__ . ............ <br />Contractor's Name ... ... License.'.. e.. <br />Installation will serve: Residence Apartment House Q Commercial C] Trailer Court ❑ <br />Motel f-1 Other.___................... _ ... .......... <br />Number of living units..,_....- .Number of bedrooms.....�Gorbage Grinder ............ Lot Size <br />Water Supply. Public System and name...... .......... ................... . ................. _.._ ................... <br />Character of soil to a depth of 3 feet: Sand 7 Silt r7l Clay F -i Peat F� Sandy Loam 1`7 Clay Loam 21 <br />Hardpan M Adobe M Fill Material- -If yes, type._..... ............ ............ <br />(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br />NEW INSTALLATION- (No septic tank or i6ep-age pit, permitted, if public. sewer is civoiloble within 200 feet,) <br />PACKAGE TREATMENT I j SEPTIC TANK Size ............. <br />__ ',...:..w,....... •... .....Liquid Depth..____ <br />LEACHING LINE I I <br />Capacity ___ ............. Type .......... ............ Motwicih_)._ ............. __No. Compartments <br />Distance to nearest: ...... *. ...... .... Foundation..... ....... .-Prop. Line_ ....... . . <br />No. of Lines .............................Length of each fino. Total Length................0 <br />'D' Box. , Tvria Filter Material Depth Filter Material ................ _10 <br />Distance to nearest: Well—_.... ............... Foundation .... Property Line...... ............Z <br />SEEPAGE PIT Depth ................Diameter.~_..,_ Rock Filled Yes r Non <br />Water Table Depth__.— . .... . .... . ... . ..... .......... t-:_.,-.zRock Size ....... . . ...... <br />Distdnce to nearest: Well......_........Foundation .......... . .......... . .. Prop, Line......._ ....... <br />✓ <br />REPAIR/AlINTION JPrev. Sanitation Permit #.. ......... ................. .....:......Date.........:.. ........ <br />Septic Tank (Specify Requirements) .................................... ............................ ......... ............... <br />Disposal Field (Specify Requirements) ...... 1�...... ...... ......... <br />AL I <br />................... . ............... ----------- . ........ <br />........... ....... ---.....__....._...........................__.......a..,. <br />(Draw existing and required addition on reverse side) <br />I hereby certify that I have prepared this application and that the work win be, den* in accordance with San Joaquin County <br />Ordinances, Stott Laws, and Rules and Regulations of the Son Joaquin Local Health District, Home owner or licensed agents <br />signature certifies the following. <br />"ll certify that In the performance of the work for which this permit is issued, I shall not employ any Parton in such manner as <br />to become subject to Workman's Compensation taws of California." <br />Signed....... Owner <br />By..__ ................ .Titles... . ... <br />,(If other than owner) <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED ...... ... _ DATE_ <br />DIVISION OF LAND NUMBER..-....................................__. .................... ....... . ............................. DATE ................ <br />ADDITIONALCOMMENTS .. ........... ................... . ........... . . .............. _ ............. .................. .......................... ........ <br />........................... ........ ................ -1- ...... ............................ ... ............... ......... . ... ........ . .. . . <br />.... ....... _ ...... ........... <br />Final Inspection bys ............... ... ....... ..... ........... <br />EN 13 24 <br />SAN JOAQUIN LOCAL HEgTH DISTRICT FM 21677 AEV. 7/76 SM <br />