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i?OR OFFICE USEt APPLICATION FOR SANITATION PERMIT yz <br /> I ...:................................................. (Complete In Triplicate) Permit No. <br /> .............. . <br /> y ;.11. . ..]�: y This Permit ExpiresresFrom.Year From Date Issued _ Date Iss /. .... .7 <br /> �( ..... <br /> Application is hereby evade to the Son Joaquin Local Health bistrict for a permit to construct.and- Install the work herein <br /> described, This application Is made In <br /> compliance with County Ordinance No. 5A9 and existing _Rules and Regulationsr <br /> JOB ADDRESS/LOCATION ........................ ....CENSUS TRACT ...... <br /> Owner's Nome ?' ....� � ......................................:Phone .¢ `� :. . �...:.. <br /> Address . : /« . ......... ... .................. . ':.......City ... .. _ ........ -- .... ..:.. <br /> . . .. . ... .. <br /> Contractor's Name ... ✓c ..License # 1.. .. . <br /> �... ............... - ..._..__. _ . Phone - <br /> Installation.will serve3 y oncepartes t.House{] Commercial OT(611or Court 0.- <br /> .•�: - Motel{]Ctther......................................................... . . . . •;,�., 4 <br /> Number of living units: Number of bedrooms Garbage`Grinder ------__.--- Lot Size ....................................... <br />' Water Supply: Public System and name- .............................­.................... ... _ ............................. <br /> x <br /> _ --- .Private <br />{ Character of soil to a depth of 3 feet: Sand❑, _Slit❑ Clay,.❑- -Peat Qom` Sandy Loam ❑ day Loam Q. r <br /> �""�iiardpan[j Adobe 0,4111 aterial ..............If yes.type............................. <br /> r (Plot plan, showing-size of lot, location of system in relation to wells, buildings;—etc: must be placed an reverse side,) <br /> t NEW INSTALLATION:t (No septic tank or seepage, it permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT,, SEPTIC TANK;{ Size.. . ..-........ <br /> ..__. : Liquid Depth <br /> Capacity � VY -. ! Material...................... No. Compartments ....V-_....:...... <br /> ' Distance to nearest: Well ... .. ...Foundation Prop. Line � .. .... <br /> --- - <br /> r .. .. <br /> LEACHING LINE ( ] " No. of Lines f.. Length of arh Ilne.. .�..............•-. Total Length 2—�..."....•-. <br /> ................ <br /> r� <br /> T �D' Bax I........ Type FilterrMaterial . . . ----Depth Filter Material ............................. ...... <br /> �{ ► Distance to nearest: We11 �....`` ............ FauAclation Property Line. ................ _- <br /> SEEPAGE PIT { j Depth Diameter Number Rock Filled Yes ❑ No Q <br /> Water Table Depth ----•-••••...................................Rock Size --.._........................... i <br /> e � ' <br /> Distance to nearest: Well .. Foundation_................... Prop. Line ...............-...... <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ata ) <br /> lSeptic Tank (Specify Requirements) ......................................... ... .. .................................. .....:........._............._......... ...... <br /> i Disposal Field {Specify Requirements) ....................................................................................................:......'_..__.............I... <br /> . <br /> : ....................•------•--............................_...........---------------...--------------.............---•-------...---................._.........._.....__....................... .. <br /> ....•--•-•.................................................. ..••••.-••-••---.....----•----•--............---•----------••-•--------:---- ................ ..... .....::..:... <br /> ' (Draw existing and required addition on reverse aide) <br /> i' I hereby certify that 1 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. Hone owner or licen- <br /> I` sed.agents signature certifies the following: - ' t- <br /> ' "1-certify that In the performance of the work for which this permit Is Issued, 1 shall not employ any person In such manner <br /> gas toaecorn subject to Workman's Co 'ensation laws of California." <br /> 5inedr:�7_,4...... ...A.... " ....... si..................................... Owner <br /> I <br /> By ....:.................................. ....--- =, ........... .. Yitle_-------......----------............... ............. .. <br /> (If other than owner) - <br /> FOR D RTM NT SE ONLY <br /> APPLICATION ACCEPTED BY ..... _. =-.................DATE - 2 <br /> BUILDING PERMIT ISSUED .. .DATE -. <br /> ADDITIONAL COMMENTS __1.............. ........................... <br /> ....................................... ._.__...._..._......... ..........................I.................. ----............................ ....._... .......... <br /> ...................*------------• - ' .-- ---•• ................. <br /> .. <br /> Final Inspection by: ... .... .. ........Date _...... . .... .... _.. . <br /> ER 13 24 1-68 4v• � SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />