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" FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT j <br />._........ � ----. Permit No. .:7S.S..�.... <br /> -•----•-----..._....._....... ._. _. ... <br /> .•. ..•-.-'.-.-•- . {Complete in Triplicate} <br /> .._.... <br /> 1 <br /> Date Issued ....... <br /> . This permit Expires 1 Year From 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 Ordina=Z�77_ <br /> nd existing Rules and Regulations: <br /> -7:2 � <br /> JOB ADDRESS/LOCATION .._....�G.... ............ ............ .............CENSUS TRACT ... _ <br /> Phone <br /> .Tr-7 <br /> Owner's NomeG, .�..J ......--- <br /> L. <br /> :L � City ......... { ........... ........................... - ------------ ----------. <br /> Contractor's . <br /> Name . �-------------- ------ -..._-License # ...._ -•---........ -- Phone ....-----•----.-_._-.:.------- <br /> Installation will serve: Residence partment House Commercial ❑Trailer Court ❑ <br /> Motel ❑Other --------•-------••---------•------_ %, . _ <br /> Number of living units:-..,/... Number of bedrooms ..../.....Gtarbage Grinder ..... .... . Lot Size ,....Z b - <br /> Water Supply: Public System and name .................__-•-_----_--__.-... . ----........--•---......----.-------------------------------------Private Q-f <br /> Character of soil to a depth of 3 feet: Sand Silt[] Clay ❑ Peat.❑ Sandy Loam ❑ Cloy Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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: 1No septic tank or seepage.pit permitted if public sewer is available within 200 feet,) <br /> .......- Liquid Depthr77=............... <br /> PACKAGE TREATMENT [ ] SEPTIC TANK T� Sizl!e_.._.__.--.__ter_.......-.-....-- . � <br /> Capacity ./ � ---. Type 0QA94o&.c-:-_ Material C llu� _A.--No. Compartments ._ `....••• <br /> Foundation .... :?�.�......_._ Pro Line . - _.�.__..... <br /> Distance to nearest: Well S�_..�'..................... . � -- - p• <br /> LEACHING LINE No. of Lines - 1 . .... .... Length of each line ...../.C?U.`.__....... Total Length ._./O ..... <br /> 'D' Box jL'... Type Filter Materia _1.14 _Depth Filter Material -.-._1 ......_.._.. ......... TP <br /> Distance to nearest: Well ......... Foundation .. .... Property Line _./._�............... <br /> ` <br /> kSEEPAGE PIT { ] Depth . ..... ........_ Diameter --._.. --------- Number .............._....._...`F.- Rock Filled Yes I] No . <br /> ` Water Tabie Depth ....................-••-•-----------------------Rock Size ----- ............-•............ c• <br /> . ro <br /> Distance to nearest: Well ........................................Foundation -------..... ....--- Prop. Line ...................... 1 <br /> IIR:PAIRcAaDOsaeSanitation <br /> Permit# - Date <br /> ------ <br /> Septic <br /> ep k IPfY Requirements) ------------------------ --- --------- -- - ----._._...---................ ------------------­------ <br /> Disposal <br /> ._.._...- -------- ------Disposal .................... <br /> .....---•--• 6� <br /> Field (Specify Requirements) ---•--------------- --- ------------ ------------- - .--- ................ <br /> .... ---------- --------- ----------.............._.,- .......---. .......... ------------------ •. <br /> I� .. . ..... u........`...'---Y.. ..............1.-....-- ...............•�-- -- ...... ................. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify.that 1 have prepared this application and that the work will be-done in accordance with San Joaquin <br /> f County Ordinances, State Laws, and Rules and Regulations of the-Scn .Ioaqu n.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 uch manner <br /> as to become ubject to Workman' Co pensation laws of California." <br /> Signed . . -------------­---- Owner <br /> I <br /> BY ..- _ ... - . ........__............................_----_---- Title .... .......... ........ <br /> (If other than owner) <br /> d <br /> ° FOR PEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ......- O -- ........7........ . . .. ............. DATE _/7 .d. ................ <br /> BUILDING PERMIT ISSUED --.. • .......... ---................... - ..............I------------ .......DATE -. .. ..... <br /> ADDITIONALCOMMENTS .... -.- - .......................__.... ..------...---.------..... __.........................->...._._...............—.................. <br /> -----------------•-- . ........ .. --- . --- --•...._.._.... ....•----• ------...... ---..._.._..---_�.2 .-...---..----_...._.... <br /> ! Final Inspection by: .............. .......................................................... --.....Date ..... <br /> ._ <br /> Ij SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7/723m <br />