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MM UFFICE USE: <br /> ............................. .................... .. APPLICATION FOR SANITATION PERMIT <br /> .......................................... (Complete in'triplicate) Permit . . .77....�:k .. <br /> ......................................................... This Permit Expires 4 Year Fre►rr►flats Issued <br /> Date <br /> r <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 Ordinance No. 549 and existing Rules and Regutations, <br /> r <br /> JOB ADDRESS/LOC <br /> OOwner' N ff?2.. .... ..1��. ✓ .. . ..... ......CENSUS TRACT .......................... <br /> wner's Name .. ....... ........ ............. ..................................... <br /> Address ............. . 10 - Phone <br /> ................. City <br /> Contractor's Name .. _..........license ... .............. <br /> ----- - --------------•----...----. .......................... ..�y..�... Phone <br /> Installation will serve: Residence <br /> WA-P-0-rtment Nouse❑ Commercial❑Trailer Court ❑ <br /> Motel©Other.................... .._... <br /> Number of living units,............ Number of bedrooms '-; Garbage Grinder lot Size <br /> Water Supply: Public System and name .................................-- •------- -•-----..... ....._....._. . ...---.....-----••---..... <br /> ------------•-----------• ... .........................Privaten-- <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ -Sondy'Loam 0 Clay loam ❑ <br /> Hardpan❑ Adobe❑ Fill Material............ If yes,type <br /> !Piot plan, showing size of lot, location ofsystem In relation to walls, buildings, etc. m stj be placed on reverse side.) <br /> NEW INSTALLATIONe (No septic tank or seepage pit permitted if public sewer is available within 200 fest,) <br /> PACKAGE TREATMENT [ SEPTIC TANK{ Size•.- <br /> Ca ci <br /> ��y��` � � ------------------•-•---......-----••-•--• Liquid Depth ............................. <br /> t1'f Yp@ Material....._ No. Compartments <br /> Distance to nearest: WetY .J45 0 f / <br /> ------------•---..._..__Foundation .G.��................ Prop. Une .8 1:...._...... U+ <br /> LEACHING LINE ( p No. of Lines �------------------- Length of each Ilne..7 ._'._..... <br /> ......... Total Length Y.9.:G'................. 1� <br /> 'D' Box ....... Type Filter MaterialDepth Filter Material 20 V ' <br /> • . Distance to nearest: Well .... Foundation ....._.... Property line <br /> ........... <br /> SEEPAGE � ( 6 Depth ................. . Diameter Number ------------------------- Rock Filled Yes ❑ No Q� <br /> Water Table Depth ..........Rock Size P <br /> Distance to nearestc Well ........................................Foundation .................... Prop. tine ....................... <br /> � <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .................................. ...... Date . <br /> Septic Tank (Specify Requirements) ...................-........................................................... <br /> ........- ............._...�............. .......... .... <br /> Disposal Fiela [Specify Requirements! ....................................... <br /> ..................................•..........................••-••---""•.._.......__._...._......_... <br /> (Draw existingd .......... <br /> d <br /> -e <br /> " <br /> ) <br /> ..................:...._._._......... ------- <br /> I ..._' <br /> ...... <br /> hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquln ,. <br /> County Ordinances, State Laws, and Rules and Regulations of the Scan Joaquin Local Health District. Horne owner or Ilcen. �µ <br /> sed agents signature certifies the following: <br /> "l-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 sub[ect�to Workman' Compensation laws of California.- <br /> Signed ..,.1 ---- ._............................. Owner <br /> By ................... ........ .................... . title <br /> other than owner! <br /> - •........ •-- ---.:....................... - <br /> f DEPART NT �USEONLY <br /> APPLICATION ACCEPTED BY . ...,........... ....... DATE `.;.. ',-......_: <br /> BUILDING PERMIT ISSUED """ -- ..... <br /> ...-------•........ ----•............................ .....•---...--- ......-................_DATE <br /> ADDITIONAL COMMENTS ................................. . <br /> .--".............................................•••. ---------.......c-........................-•---.............---.----•..._.... . .................................----------..-.....' <br /> E.H........ <br /> I....-- <br /> --....b .....�v. .......Final Inspection by: - �... ...................•.....:. .........-.-.-.......---....--............- ........._... <br /> ...----• .... ......._ ... .. .. . ...................................Oats ....:. .;.... ..... _..7...-.-...-.-.... <br /> 13 2a 1-6i3 5� SAN 1=1NLOCAL HEALTH DISTRICT $/7h <br />