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FOR OFFICE USE. <br /> ................... •-•----•-• -- APPLICATION FOR SANITATION PERMIT 7 7—j 7 S� <br /> (Complete in Triplicate) <br /> ......... ........ Permit No. <br /> ................... <br /> ............................ <br /> This Permit Expires I Year From bale Issued bate 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 Ordinance No. 649 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..---.h�`�.�_-- -----. --- ............................CENSUS TRACT .......................... <br /> Owner's Name ....... --•---- Z: ---------------•----_ ._...._........,...... Phone ......... . <br /> Address ................City <br /> Contractor's Name . ............•----_-...License #YP.91..11... Phone <br /> Installation will serve: Residence j11(partment House Commercial❑Trailer Court 0 <br /> Motelp Other......................................................... <br /> Number of living units:.... Number of bedrooms _., ..--Garbage Grinder ............ Lot Size .1.+...iE... .... .. .. ...... <br /> Water Supply: Public System and name ­.11 .......Private ' <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam <br /> Hardpan❑ Adobe 0 Fill Mpterial ............ 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: (No septic tank or seepage pit permitted if public se r Is avail le within 200 feet,) <br /> PACKAGE �. �. <br /> TREATMENT [ ) SEPTIC TANK f ] Size.... 7. Liquid Deptit <br /> Capacity ----------- ---•t•-- Type ----------_------- Material...................... .No. Compartments ...................... <br /> Distance to nearest: Well ..........................Foundation ................ .. Prop. Lina <br /> ._ LINE j � No. of Lines --------�-------._.- Length of each line..------.�.C%...-_-.... Total length ...RP............... ' <br /> LEACHING L_ <br /> 'D' Box ------------ Type Filter Material ....................Depth Filter Material ___....................._............_..... <br /> Distance to nearest: Well ........................ Foundation ..-..................... Property Line .............._........ <br /> Depth a-X/40AIDiameter .•-------------- Number ........../...._....._.. Rock Filled Yes � No <br /> .�..��.,� Water Table Depth •--•----------------------------'. _-._------...Rock Size .. ". <br /> / . <br /> Distance to nearest: Well .............................. ........Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................. ------___ Dat ............ - ••--------.) f . <br /> Septic Tank (Specify Requirements[ --------------• r '.. . .. ........ <br /> Disposal Field (Specify Requirements( <br /> . <br /> -------- r <br /> ------------------------------- -------------------------- -- ...------•- --- ------------._....._I.,---------••----•- - <br /> (Draw existing and required addition on reverse side) <br /> 1 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. 1 <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 Workman's Compensation laws of California." <br /> Signed ------- - -•-• -- • -- ------- Owner <br /> - <br /> BY ---- -------- -------- -- <br /> - -------- -- --��-- --��- .-:. -, -----....------...--- Title _........---.-------------------.-._... ........................ <br /> ---�--• I <br /> {If a# er than owner( <br /> FOR DEPARTMENT USE ONLY .� <br /> APPLICATION ACCEPTED BY -. � �—z� D&TE1..... = = ? <br /> BUILDING PERMIT ISSUED ----------------- ----- - ' ... DATE <br /> ADDITIONAL COMMENTS .-- •---- ------------------ <br /> -- ,...., :..:_....__... <br /> --------------- <br /> ------------ <br /> -------------------------------------- -- ---- ---- <br /> -•-.... -•.-..--•-------•---- <br /> -• .--- <br /> Final Inspection by- --- ------- <br /> -- ----•-•---... ------------ Date _... .... <br /> 13 2� 1-68 Rev. SAN IOAQII#N LOCAL HEALTH DISTRICT 8/7lJ 3M <br />