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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �� <br /> ComploM M Triplicate) Permit No. ........ 2:3.. <br /> .......... ............•................. <br /> ..... This Permit Expires>I Year From Doh Issued Date Issued <br /> Application is hereby made to the San 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. 549 and existing Rules and Regulationst <br /> r <br /> JOB ADDRESS/LOCATI /..�../�..C... �........... .:. !p.G[,........�NSUSTRA�T .......................... <br /> Owner's No ...y��'�`!lL:................ D. : ..................................... <br /> AAddress ..._ -ri. :� _ _... .l a� ......... ..................... City .... ....... ._ . .. .0.......... <br /> Contractor's Name ....... <br /> �Q. r '..oa !QNi .,�/ icense i fl .: PhoneQ.��f. <br /> Installotion will serve: Residence Q Apartment House Commercial f3 railer l,mm <br /> Motel[I Other............................................ <br /> Number of living units:..... Number of bedrooms ---2�....Garbage Grinder . "" Lot Size ... c ...��. r� ._ <br /> Water Supply: Public System and name _ ......._........-•................................Private, <br /> Character of soil to a depth of 3 feet: Sand n Silt 0 Clay 0 Peat Q Sandy loam 4r" Clay Loam D <br /> Hardpan C] 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 240 feet,) <br /> PACKAGE TREATMENT / <br /> ( ] OPTIC TANK+'' Size.... -1.�.,�.-.�,,t'i� ---•--- Liquid. Depth ...� ............ <br /> Capacity msa.G4ype ..A aterial-- -- No. Compartments .. <br /> Distance to nearest: Well ` ,1.a_.......................Foundation .../0-*........ Prop. Line .. .--.-.�o <br /> LEACHING LINE fV VV No. of Lines ....iR............... Length of each line. Total Length ..../l<'0..`.........D <br /> 1 " o <br /> 'D' Box ....L..... Typo Fil#er Materia{ .lT ...Depth Filter Material ... ... .................................. <br /> l �f o <br /> Distance to nearest: Well .�C?G.?_�....._ Foundation ........................ Property Lfne ..�................. <br /> SEEPAGE PIT Depth *?Lr ....... Diameter �s a- <br /> .................... Rock Filled Yes � No i <br /> Number ........_.. <br /> r � <br /> Water Table Depth ......� Rock Size .... ............ ......... f <br /> .� <br /> Distance to nearest: Well .-��(f....................•....Foundation .. � ........ Prop. Line ..4i .._.........J <br /> RIPAIVADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) ......................................... ..........: ..---..........................---................. <.................... .... <br /> Disposal Field (Specify Requirements) ............. ............... ................ ......................................... ...........................I.......... <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 Sem Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Load Health District. Hem owner or licen, <br /> sed agents signature codifies the following: <br /> "I cor ify 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 ---- •--• ................... ............. ----•-.. ..... <br /> By ... ---- . Z ,- <br /> ....... title .... GB.... <br /> ( ofMn owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY '.-.. ... --- DATE : - ....... <br /> . --_ ---- -_- , <br /> BUILDING PERMIT ISSUED .. <br /> ............ ...• ---------- • ----- ---------•------ -----------------------------------------------DATE ....:_.. <br /> ADDITIONALCOMMENTS ............------ .......... ........................_......_..----........--•---..._......... ------.........-_............-----•....---........ <br /> .................-..................---.-----•---...._._....--------------............................_.............-----........--_. .................................... <br /> .. .............. <br /> =--------------------------•--------•---------.-..................._......_.:.__........_.....--..... <br /> Final Inspection by: .._. = ----- ................................. ..............—...----...... . - ��..�. ... ........_... <br /> • ...............Date .,L'....'�-� ...---...... .....-----•----- <br /> Fi 13 21l 1-6y Rev. 5r4 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />