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FOR OFFICE USE,: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ...--...... <br /> •--•-............ . - <br /> (Complete in Triplicate) r <br /> _. Date Issued ..I-,n�7 7 5 <br /> This permit Expires 1 Year From Date issued <br /> l the work <br /> Application is hereby made to the San Joaquin L'otaNiHealtaUDYtOict nante or a No549 and ex sting Rulesrmit to construct and talnd Regulat ons:e1n <br /> described. This application is made in compliance <br /> / CENSUS TRACT <br /> ................. <br /> JOB ADDRESS/LOCATION l•• "" <br /> Owner's Name ..... ./�&'� - � -•-......... ..P?In <br /> ................... <br /> Address // � �........ <br /> � ....r-.....• City <br /> f ... Phone ---.........../ •--••...................... <br /> Contractor's Name ................... .....•---------------------- ---------•------••-•----.....- <br /> Installation will serve: Residence ❑Apartment House-p <br /> Commercial ❑Troller Court 0 <br /> Motel 0 Other .- _ _ <br /> Number of living units------------- Number of bedrooms _.Garbage Grinder ...........- Lot Size ._........._....__.......___..:-.---•• <br /> ................... Private _ <br /> { <br /> Water Supply: Public System and name ---- ......... --- -----•-•- Cloy Loam <br /> Character of soil to a depth of 3 feet: Sand .Silt❑ - Clay ❑ <br /> Peat Sandy Loam-❑ Y ❑ <br /> Hardpan ❑ Adobe.❑ Fill Material ........... if yes,type -------_ ---- •-------•• a <br /> {Plot plan, showing size of lot, location of Sys min relation .to',wells, <br /> buildings, etc. must be. placed on reverse side.) <br /> it permitted if sewer is available within 200 feet,] <br /> ri <br /> t NEW INSTALLATION: (No septic tank ors age P p y ... Liquid Depth <br /> SEPTIC TANK� 5ize-..�----••--•---•---• ............. q p -.....---....,__.. . <br /> No. Compartments <br /> PACKAGE TREATMENT [ ] ..................... <br /> Capacity <br /> #erial - <br /> -....-._Foundation . . Prop <br /> Distance to nearest: Well ..- . <br /> T =••----•-•---- o Line .. <br /> LEACHING LINE No. of Lines --.---.�---•-•••------• Length f•)eoch'•line--... . <br /> Tota! length 1 •:..... <br /> O <br /> r De th Filter Material �� ...................... <br /> 'D• Box ............- Type Filter Material ...:!: - p <br /> .. PropertyLine .. .--- ' <br /> ,A � r.... Foundation ...................... � <br /> Distance to nearest: Well : - 5-� - <br /> '� _ <br /> ... ....... Rock'Filled Yes ❑ <br /> SEEPPIT Depth ....... ..•--- Diameter --•---..._.. Number :.... .......... No <br /> r Water Table Depth _...----••-••.............•--••--•-._...__. <br /> .....Rock Size .---•---------------•-•--•------ <br /> Distance to nearest: Well ........................................_ ....__ �. . <br /> Foundation . ••-- • . op• <br /> r Line <br /> ..,-.� �•�„ - �� ate ..................•-•-••-----•-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit�1` .•---••......-----•-- ~••-......."' <br /> Septic Tank (Specify Requirements) ---------------------------------__................ ------•--•------•- <br /> -•---•----•--- .......... ------ .......................... <br /> Disposal Field (Specify Requirements] <br /> -----•--------••---------------- •-...-...----•--•-...--..--------•------------------------•------ .................................. ............... <br /> - - . <br /> � (Draw existing and requiredaddition on.reverse side) <br /> ne in accordance <br /> I hereby certify that I have prepared this application i i glationsthat the of the San°Joaquin LocaloHealth District. Home'th San Joaquin <br /> owner or I cen- <br /> County Ordinances, Stale Laws, and Rules an <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit Is issued, l shat not employ any person in such manner <br /> { as to become sub' to War a C nsation laws of California." <br /> I - Owner _ . .. <br /> Signed <br /> -•.....:.........•-• Sitle ..................... .................................. <br /> (if other than owner) <br /> l = USE ONLY <br /> f FOR DEPARTMENT U `/ <br /> DATE _....-, .�.... ..I•,�- ..._. <br /> APPLICATION ACCEPTED BY==----------- .....------....---.............:..DATE ...-----:... <br /> BUILDING PERMIT ISSUED .............••--......................-----•-•------.... <br /> ADDITIONAL COMMENTS •----••----------------•-----•---•-----•--••----•••-........:............... '....__,... <br /> - ...-... ......................• ..--- ........... ...... .: - r�2 .-..... <br /> .....------•-----.... .................Date .. '! <br /> Final Inspection b ........... ............................... <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT _;�,..._.._. ., _,�,, <br /> �.... _ 7/7 <br />