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r FOR-OFFICE USE: APPLICATION FOR SANITATION PERMIT � qq <br />.......-_.. � Permit No. <br /> ..... <br /> ....... <br /> . .. .. - ------•�-..- (Complete in Triplicate) <br /> _.. �..���.. "a <br /> Date Issued <br /> This Permit Expires 1 Year From Qate 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 CountyOrdinanceNo. 544 and existing Rules and Regulations- <br /> JOB ADDRESS/LOCATION :. ................ CENSUS TRACT ................... <br /> Ur <br /> Owner's Name ................... ?e-._.. aa c <�_._.. <br /> .... <br /> Phone <br /> Address �`' <br /> - ��- ----City -•�-•.--- - <br /> S f� r +�. License # .+ ._��---- Phone .-�.'?6�l... <br /> Contrattar's Name .. ---......�.�.°... ..�- ....---- ��-----•----- t--- - ---... � - <br /> Installation will serve: Residence E&4partment House,] Commercial ❑Troiler Court [] <br /> Motel ❑Other .-......... --------------- ----•----- <br /> Number of living units:.... Number of bedrooms _.3......Garbage Grinder ._.._..----- Lot Size ...�� �......•••.......... <br /> I Water Supply: Public System and name.-.-.-...........-------------------.. ------._..:-,-:- ....--------------:------- Private <br /> _. <br /> Character of soil.to a depth of 3 feet: Sand'❑ Silt F-1 Clay ❑ Peat❑ Sandy Loam [I Clay Loam ❑ <br /> .T <br /> Hardpan E] Adobe ( Fill Material�_._I.m-•-.. If Yes, We --------------- <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'[* Size....- ----------- -- Liquid Depth ....... <br /> Capacity ..� ....- Type ( . -' $'._ Material... 0 �- No. Compartments -A............:..••� <br /> ' G �. ._......� <br /> Distance to nearest: Well Ca----.r•--------•••••.•-- <br /> -.Foundation ... �{......--.. Prop. Line --- <br /> LEACHING LINE No. of Lines . Length of each Bine.....-S-�. ............. Total Length <br /> --•�•-7Q-f-•.••••••---•� <br /> 'D' Box _-� ... Type Filter Material .4,-c.*......Depth Filter Material ...ff.. .................... .......... <br /> Distance to nearest: Well -.-5-14'..0 <br /> ._. . � _ Foundation .1�_.f......... Property Line 7;F................­. <br /> ' q0 Rock Filled Yes L4 No <br /> SEEPAGE PIT € ] Depth A�._... Diameter .._,. .� __. Number - ---- - <br /> ri <br /> .. .. > <br /> Water Table Depth _...-._ . -- -........Rock Size a-' °Z ' <br /> Distance to nearest: Well - .-... =�f- ---------------Foundation .. _.�.¢ ...... Prop. Line ----- ......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit=# •----- ......... .......... Date ---_._.----------..-------.-...._.) <br /> Septic Tank (Specify Requirements) -- ...-........ ..---- •---- ------ ----- - ---------- --------- -------_..._...-._........................................ <br /> Disposal Field (Specify Requirements) .__...._.-_ --------. --------- - --------------- • • .........---------..._....__..._......._..._ <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 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 W rkman's Compensation laws of California." <br /> I Signed .:.. ... . ... Owner <br /> ` <br /> By = - . ..... .............. ............•-- •. <br /> Title ........................... <br /> i (If other than owner) <br /> FOR DEPARTMEW USE ONLY <br /> _sem-�--=- ---- --•�-•--�_.._,�-=-r_� <br /> f 5 .:......5-. <br /> APPLICATION ACCEPTED BY . _ DATE <br /> BUILDING PERMIT ISSUED _-.--.-------- - DATE ... ....................................... <br /> ADDITIONALCOMMENTS .. .. - ----------- .................................... ----.... ......... .....................__.............----..------ <br /> ........................... ..... .....•- r �. <br /> � � -�� �- . <br /> ................. r.� <br /> --- ... <br /> ------- --•----- ------ �G <br /> _. -. <br /> Final Inspection by: ....----- ..............................'pate .... ^. .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7/723 M r <br />