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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 0 <br /> .. Permit No. '...� .. <br /> .•.._- {Complete in Triplicate} ' <br /> ...........................................I..... r/ <br /> ..-. This Permit Expires 1 Year From Date Issued Date Issued ................-7'.. <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: ,✓ <br /> JOB ADDRESS/LOCATION ,..... _Q.. .._... /,.:....,��l�I /....... ..................CENSUS TRACT ..................... <br /> w... <br /> Owner's Name ..... <br /> /�, �A ...... e�Yl.V, ------- -------------------Phone <br /> Address .f/ ...... .......... .... City ..�, ................................... <br /> Contractor's Name ...... --- -- - -----------------------------••-----•-•--•License #�7i .. .. Phone .: c ,� . <br /> Installation will serve: Residence JQ Apartment Housed Commercial ❑Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units..--/------ Number of bedrooms ...._/......Garbage Grinder ./V-Q_. Lot Size .......... <br /> Water Supply: Public System and name ------•------------------ --------------------------------•----•-----------------------.._......_....---......Private <br /> i <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam 0 <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ............................ <br />: <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 seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ } SEPTIC TANK:t I Size................... _--------_-------------- Liquid Depth .......................... <br /> Capacity -_---------------- Type .................... Material_----•-----..__..----- No. Compartments <br /> Distance Jo nearest: Well ....................................Foundation Prop. line ...................... r <br /> LEACHING LINE ( j No. of Lines ................ Length of each line---------------------------- Total Length .................... <br /> D' Box ------------ Type Filter Material ................:...Depth Filter Material .................................+x.......... -� <br /> Distance to nearest: Well ........................ Foundation ----------------- ...... Property Line ....... <br /> S <br /> 4 <br /> SEEPAGE PIT [ j Depth -------------------- Diameter ................ Number ----.-----------------..---- Rock Filled Yes [J... ,IiNo [J <br /> Water Table Depth --------------------•=------------------------.Rock Size ...- .......................... , <br /> Distance to nearest: Well ________________________________________Foundation .................... Prop. line . .............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. ' <br /> SepticTank (Specify Requirements) ------------------- ------------ --•-----------------------------...---•----------•-••-•-------------------.......---•--------------.._...... ' <br /> r - . <br /> Disposal Field (Specify Requirements) ------ .(� ,� ��"�,r1 X/_/..V,&. ----, .................. <br /> %-� ---......................------------------------------------.............................-........................................ <br /> . <br /> ........................................................-----------------•--..---- ------------...-------------------------------------------------------....._...............---------- <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 Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or liicew <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 Haws of California." <br /> Signed .... ....... •-------- ..../he <br /> _ _. ... Owner <br /> BY ..... .................................. _........ title .(If other than <br /> F R DEPARTME T USE ONLY <br /> APPLICATION ACCEPTED BY __gDATE ..�f <br /> ... ------ <br /> BUILDING PERMIT ISSUED ..---.......I------------- ---- -•---------.........DATE ._.__..._..............._._.... •... <br /> - -------------------- - - <br /> ADDITIONALCOMMENTS .......................•-••---...---••----•-----._....__..._....------...---------•-----------------.....----....:........................... <br /> ------------------------------------•---------------------------...4.........._... .--------------............................................................--•...................................... <br /> ------------------------------------ ... ........ <br /> -r- <br /> Final inspection by. .. ....... .......................................6 _..._ -• = <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � <br /> 13 24 <br /> E: <br /> H. 1•'68 Rev. 5M ,, .. ... _. . ..-._ ._.. .,.,-._..,..__...._ .. '. _ . .. ._,_..7172 3 M <br />