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rvx urriUx VMS APPLICATION FOR SANITATION PERMIT <br /> .................................................... <br /> (Complete In Triplicate) Permit No. ..................... <br /> - - Date Issued <br /> .... This Permit Expires I Year From Date Issued <br /> Apaplicatlon 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 comp�liiance €th County Ordinance No. 549 and existing Rules and Regulatlonse <br /> JOB ADDRESS/LOCATION � 9 .:V` 2.. .. .........................................CENSUS TRACT <br /> Owner's Name . .. ...... .. .•• ...... ................... .............................. .. ...............Phone _ <br /> x�ddress . <br /> � .............City ." _... .: -�-......... - <br /> Contractor's Name ..... .... <br /> ........ ...:.... ham_ ..... -....._._'.......License '�4L-3... Phone <br /> .. . <br /> Installation will serves Residence❑Apartment•House[] Commercial❑Trallw Court E] <br /> Number of living units:............ Number of bedrooms .--..."....Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public and name •.......................... ...................................................Private❑ <br /> Character of soli to o depth of 3 feet: Sand❑ ' Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam <br /> 16 <br /> Hardpan O AdoboAp Fill Material ............If yes,type............... ............ <br /> !Piot plan, showing size of lot, location of system In -relation to wells, buildings, etc. must be placed an reverse `idea <br /> NEW INSTALLATIONS (No septic tank or seepage"pit permitted'If public sewer is available within 200 feet,] <br /> ! PACKAGE TREATMENT ( } SEPTIC TAN ..J Size...s`.5e dZ . _. liquid Depth +. <br /> I ..... .-- ............ <br /> ! Capacity .. ... Ty :!-� . Material . ..... Na. Compartments ....1�� <br /> ..... ... ........ . <br /> Distance to nearest: Well' ./yv.XC14......................Foundation .. _.. ............._. Prop. Line. . <br /> LEACHING LINE'" No. of Lines .." ''Length f each line.....�r.C-�.......�.� Total Length . ..1 . .. <br /> If <br /> 'D' Box ---•--•----:``Type Filter MateriaP�.� .f.....Depth Filter Material .................................... <br /> - Distance to ne+Srest�Well" -=- Foundation ....... Property lints .... .. <br /> ry. <br /> SEEPAGE PIT Depth '_.. ...... Diameter .... ..... Number <br /> Roc Filled Yes No <br /> Water Table.Depth ••--._f .............................:...Rock Size .... .......:�.1.(...... <br /> ........Foundation ... ................ Prop. lino <br /> Distance to nearestc Well .......NA2' ....... �� f ...... ...... <br /> I REPAIR/ADDITION(Pre%. Sanitation Permit 91t ......... --•---•. ` .................. .Date ................................ .I <br /> Septic Tank (Specify Requirements) ............... ....................... . .................................................. ..................._................ <br /> Disposal Field (Specify Requirements) ....... - .......... ... :......('�.. 5............. <br /> — 1: - •---------------• ------•---..... .....-•---- .......- --............................----........................................----•---.. <br /> ............................................................................................................................. <br /> (Draw existing and required addition on reverse side) <br /> ; <br /> hereby codify that I have prepared this application and that the work will be done In accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the,San Joaquin Local Health District. Home owner or llcen- <br /> •,sed agents signature certifies the following: <br /> ' "i certify that in the pert ante of the work for which this permit Is issued, I shall not employ any person In such manner <br /> ars to become ubjec t orkman's Co#nsc <br /> tio lawsof California." <br /> . /f;. neC .....v` .. ..�t . ............ ................. <br /> $Y :. . <br /> (if other than owner) <br /> F FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .--_ .- ...... DATE ..-- 'x`'.14.......:.............. <br /> BUIIDING PERMIT ISSUED .µ::. _.. <br /> ...................:. ..._.................._....... ...DATE>..................................... <br /> ADDITIONAL COMMENTS <br /> ............................................. ... ...... ........................ <br /> ....--.. •............ .... _. ........ <br /> FinalInspection by: _.. ....... . . ...... ... ...-----...._._................"----_.......---....._ .......Date .. ... �..-----.......... <br /> EH 13 2!S 1-60 ll SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />