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t FOR OFFICE USE: <br /> / s APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permifi No: . <br /> �C <br /> ,.... . ./,/ ........... <br /> •.... (/ This Permit Expires if Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin local Health Distr-ict,f6r a permit to construct and install the work herein <br /> AT <br /> descri <br /> bed' This ap i •tion a compliance with County Ordinance No. 649 and existing Rules and Regulations: <br /> I JOB•ADODRESS L OS o <br /> . ..�.., - _ - �.,:,.- •�•... ••�. . `�fCd'4'.r.,,�-G.,-z�ENSUS i'RACT ......-..---..:....-T.... <br /> Owner's Name .. - . - <br /> . .. .r. ..S.P . _.� .�L..---........ Phone <br /> Address .................- ........ L.?... = .........'City .. ., <br /> .....__...._............---•.......... ... ...-. <br /> ,.... <br /> Contractor's Name ---. ...- --- .......-.license # °. ./ --2....... Phone? <br /> Installation will serve: Residence partmenf House] Commercial ❑Trailer Court <br /> F' Motel ❑Other................... <br /> Number of living units:-_1---....'Number of bedrooms &........Garbage Grinder -1�J .-- Lot Sizez7_ <br /> Water Supply: Public System and,name ..................................... .....Private Zp— <br />' Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay,❑ ..Peat❑ Sandy loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe ill Material,,*. --- If yes,type --------------------------- <br /> (Plot <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 /> TREATMENT [ ] SEPTIC TANK[ Size---�,/s-x- --......••... <br /> PACKAGE TR .._.... Liquid Depth <br /> _.. <br /> I Capacity .. Type ��, Material. No. Compartments <br /> 'Distance to nearest: Well .....Ill ..Foundation <br /> ............ Prop. Line <br /> ��_C'f.............. <br /> LEACHING LINE [t]­�_No. of Lines ....... -- ........ Le gth o each line..- ......... Total Len th rl__al <br /> D' Box /es-..-"Type <br /> Filter Material __..__Depth Filter Matenal Z <br /> h ) -- {.............................. r <br /> Distance to nearest: We'll .... ./_ '....--'Foundation ...� ............. Property Line ....... <br /> SEEPAGE PIT [ 7 Depth .�, �-:-..::.. Diameter Number ---•....�.................. Rock Filled Yes j��lo <br /> I <br /> ! - i <br /> Water Table Depth Rock Size .. 1,h- ?C._ <br /> ................... <br /> Distance to nearest: Well ......1_Qp. .......................Foundation /9. ....... Prop. Line 3 <br /> REPAIR/ADDITION(Prev. Sanitation Permit 56s ..............._ ---.- Date <br /> Septic Tank (Specify Requirements) ................:......•__________-____--------------- <br /> Disposal Field (Specify Requirements) .......:........................................... <br /> ........................ f <br /> ..................f-------------------------------------------- - <br /> ....------•-• <br /> [)raw existing-an- d <br /> -- -----re----quired addition---------------...-.----•--_- ._.---...--sid-...)................................ <br /> .---------- <br /> . <br /> .--------------on reverse e <br /> 1 hereby certify that I have preparethis application and that .'the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of t6 San Joaquin local Health 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 /> Signed <br /> �� . _ Owner <br /> By ..-.. = 1/ - -- :.. . ............ . fiitle -......-.. ..... �: ...-. <br /> ' <br /> (If other t owner) i <br /> )F EPARTME USE ONLY <br /> APPLICATION ACCEPTED BY .. .... ................a.c........_ DATE .... ----- •-• ---- <br /> -----••---•-..... . <br /> BUILDING PERMIT ISSUED ........:.......................'____,_...--.... ..............DATE <br /> ADD T1 A COMMENTS .......--•- <br /> .. <br /> .......... <br /> ..-•............. <br /> ..- <br /> //�. ............. . �.1. .. _ :-,.._.. ............ = ..:- ..........._ <br /> ...... ................. ...._. .F -•-•--•-••-- . ............................................... . <br /> . . ............. <br /> . ... . ..... <br /> Final Inspection by: -- -• •---•• .:............. ..........Date <br /> —_--.- - JOAQUIN, LOCAL, HEALTH. DISTRICT <br /> E. H.13 24 1-'613 Rev. 5M <br />