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FOR OFFICE t,slw: <br /> APPLICATION FOR SANITATION PERMIT <br /> :............ ......................... <br /> _"_...... lComplete In Triplicate), Permit <br /> i ................ .. ..---.. ........... <br /> This Permit Expires 1 Year From Date Issued Date Issued ---_•__-•_-_-..._-.. <br /> -Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal) the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO ��►_ ��._..... -------------------- CEN5L15 TRACT <br /> __..._•------------------- _ ----................... <br /> Owner's Name <br /> ----------------------------------------------------- ..........------..Phone .---------- --- ............. •-•--- <br /> Address ................ <br /> i ..'•-- <br /> City <br /> Contractor's Name .< �.�✓.._ -•� <br /> .. License # .- Phone <br /> Installation will serve: Residence['Apartment House Commercial OTraller Court 0 <br /> Motel ❑Other---•..............................•........._ <br /> Number of living units:---- Number of bedrooms -A.....Garbage Grinder ............ Lot Size ........................... ............... <br /> Water Supply: Public System and name .................................... ----------------­—------------------------- .......................Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam a Clay Loam ❑ <br /> � <br /> Hardpan❑ Adobe 0 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 /> F NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) V' <br /> - <br /> PACKAGE TREATMENT [ SEPTIC TANK ] Site........--------------------- .................... Liquid Depth ............................ 6 <br /> O <br /> Material.......... :.... —No. CompartmentsCapacity <br /> Distance to nearest: Well Z <br /> ' ------ .................... -....- Prop. Line <br /> LEACHING LINE [ ) No. of Lines ------------------------ Length of each Lline_._........................_. Total Length • <br /> 'D' Box .._-------- Type Filter Material ........................Depth Filter Material ............................................ <br /> r <br /> Distance to nearest: Well .....:................!. Foundation ........... --. Property Line .....I.................. C <br /> r DepthSEEPAGE PIT [ j ----------------_- Diameter .__..........{.. Number ........................ ._. Rock Filled Yes ❑ No Q . <br /> i � <br /> Water Table Depth ------------•-----------••--•-- ...............Rock Size •-=-------•• ..............•• <br /> Distance to nearest: Well ........................ <br /> --':.W:.::`'fiiundatian`..............I------ Prop. Line ....................... <br /> REPAIR/ADDITION Prev. Sanitation!Per it9 Date ................. j <br /> Septic Tank {Specify Requirements] --- ........... =------------•-••-------.....--------•--••--- ............................ •-•••--------.................. <br /> Disposal Field (specify Requirements) _19 �.�.,, -_.--�--•lc� � ........... <br /> _� -•--- ----•--•-•-----•--•----••--•............... ...... --------------- ........................... <br /> ------- --- ------------------------ ----------•=........_...................... •---•...............•-----...._..._...------.......I.........-----.-- <br /> (Draw,existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, State Lavers, and Rules and Regulations-of the San Joaquin Local Heal&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 subject to Workman's Compensation laws of California." <br /> f Signed ----..---- --..._ _ Owner <br /> --- -- --- <br /> BY Title .t .P of 3<--•...... ..............•--........ <br /> {if other than ownerl <br /> FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- --- ...... -------- --- •--- -•-----•- ....__.... DATE . ...� .......... <br /> BUILDINGPERMIT ISSUED -------------------------•------ -----------------------------------------------_........__DAT£ _-:---- - ......................._..----- <br /> ADDITIONAL COMMENTS ----------------------------------- <br /> --------­­­-------------------- <br /> .-•------------------------- --------------•-•------------------- ................-•­.........................................-..---. --------- ------•--------- -----------------------. -----------• ................... <br /> •-- --- ••--........L <br /> Final Inspection by: - Date ......1..._. ...... ....... <br /> J 3 2h 1-6t3 Rev. I SAN JOAQUIN LOCAL HEALTH DISTRICT --8/7h 3M <br />