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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />....................................................... in Triplicate) <br /> (Cohnplet• Permit No. ..7 S3/,o <br />.......................................................... <br /> ....... ., . . This Permit Expires 1 Year From Date Issued i)ate issued <br /> Application is hereby made to the San Joaquin Local Health District fora permit to constr4d and install the work heroin <br /> described. This application Is made In compliance wit County Ordina No. 544 and existing Rules and Regulatlonss <br /> JOB ADDRESS/LOCATION ��`. ..�/.... .. ...rL.S.......... ....... ..f '" .........................Ci;NSUS TRACT .......................... <br /> Owner's Name ..... t.......e...... .. ..... .......................................Phone .................................... <br /> Address .......... . , 17 ? . . . ....City ............................................................................ <br /> . ... ..... ... . ... . <br /> Contractor's Name ... ... ...............License #Li..................... Phone .............................. <br /> Installation will serves Residence Apartment House❑ Commercial[]Trailer Court ❑ <br /> Motel p Other............................................ <br /> Number of living units:_....1_... Number of bedrooms ---_.....Garbage Grinder ...... Lot Size ............................................ <br /> Water Supplys Public System and name --_-_--------------- ........--_--....----....--.-_...................................................Private <br /> Character of soil to a depth of 3 feet: Sand❑ Ilt[JClay ❑ Peat❑ Sandy Loam ❑ day Loam ❑ <br /> Hardpan Adobe❑ Fill Material ............ If yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to welts, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) . <br /> PACKAGE TREATMENT ( 3 SEPTIC TANK f ] Size..................................I............. Liquid Depth .........................,� <br /> Capacity --------_---_--_ Type .................... Material...................... No. Compartments ----................� <br /> Distance to nearest: Well _.Foundation _..._. Prop. Line <br /> LEACHING LINE [ D No. of Lines --------------- ------- Length of each line............................ Total Length ............................. <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ <br /> Distance to nearests Well .................. _-- Foundation ........................ Property Line ............: <br />• SEEPAGE PIT Depth •. ........... .. Diameter _............... Number ----....-..............._... Rock Filled Yes No ❑. <br /> Water Table Depth ................:.........••-••.....---.........Rock Size --- ----•-- .................... <br /> Distance to nearest: Well ....... ................................ .................... Prop. Une -_...---............ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) .......................... .--....._ . . ................................ ............._... ............................ <br /> Disposal Field (Specify Requirements) ----�-e 1z- la...rP�.. ..... ..._. .....................-..... ............ <br /> .P. .... ........ . - ..................•--•--..... <br /> .-....--•- ................................ <br /> (Draw, existing and required ditian on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with Sass Joaquin <br /> County Ordinances. State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Ilan- <br /> sed agents signature certifies the following- <br /> "I ceWify <br /> ollowing-"I.ceWify 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 /> By .:`.."........................................... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ........ <br /> ............................... .. ............._.. ..... ........................... DATE.....—Y- .mss................. <br /> BUILDINGPERMIT ISSUED .................................................................................................•---....DATE ..........---................:......_-----. <br /> ADDITIONAL COMMENTS ....................................... <br /> .............................. <br /> .............-----.'..........-............................................ ................................................. ...---•-----.................---- <br /> .......................... .............. ---------......... ....__.............. ................._ <br /> Fina! Inspection by: ............... ......_.....-----••----.....-. . . . . . <br /> Date ...5J ..� ... <br /> EH 13 2h 148 ftev• 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />