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FOR OFFICE USE: APPLICATIA FOI SANITATION PERMIT <br /> Permit No. -__-" <br /> --------------- - <br /> ___------------------------------------- - (Complete in Triplicate <br /> -- --- - - --- - - <br /> Date issued G��3 <br /> This Permit Expires 1 Year From Date issued <br /> l the work <br /> Application is hereby made to the son compliance c l Health <br /> District <br /> ounty orOrdinance permit <br /> to cons <br /> and existing Rvlestalnd Regulations,.rein <br /> described. This application is ma <br /> _ CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOCATION --------11-13-0---N-- ----�U ---------- ---- -----------Phone.-�/�.7-"9'e nt? -------- t <br /> Owner's Name _W�------------------------------ <br /> AddressLcense # -� 2fg--3------ Phone <br /> Contractor's Name -.-f j� ---=-� �---�'�--- '"-""" ------- - <br /> ------ i <br /> Installation will serve: Residence Apartment House Commercial ❑Trader Court i❑ <br /> Motel ❑Other ---------------------------------------- -- <br /> Number of living units-.---I------ Number of bedrooms"" rQ----Garbage Grinder <br /> Lot Size ----------------------- <br /> Public Sstem and name --- -------- ----- -- - ------------ ------ ------- ------ --------- - --- <br /> -- <br /> ------ ----------------------- Private ❑ <br /> Water Supply: Y Clay Loam ❑ <br /> Character of soil to a depth of 3 feet: . Sand'❑ Sdt❑ Clay F1 Peat F-1 Sandy Loam -[IY <br /> Hardpan ❑ Adobe 50 Fill Material - --------- If yes,type ---------------------------- <br /> (plot <br /> ------- ----- -(Plot pian, 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 sewer is available within 200 feet,) <br /> Liquid Depth -------------------------- <br /> PACKAGE TREATMENT ( � SEPTIC TANK f I Size----__-------------- ---- ------------ ------- <br /> q p <br /> Material- - No. Compartments ---------------------- <br /> Capacity <br /> .-----------•--- <br /> Capacity ---------------- -- Type -------------------- "-[ <br /> ` --- Pro Line _". <br /> ' Distance to nearest: Well ----- ---------- Foundation ----------------- P <br /> Length of each line-------------- ------ ------ Total Length <br /> LEACHING LINE [ 7 No. of Lines ------------------------ <br /> De th Filter Material -------------------------------------------- y <br /> 'D' Box ----- ------ Type Filter Material ----------- -------- <br /> Distance <br /> P <br /> Distance to nearest: Well ------------------------------- Foundation ------------------------ Property Line. ------------------••---- <br /> De Depth --- Diameter ---------------- Number ---------.------------------ Rock Filled Yes ❑ No I❑ <br /> SEEPAGE PIT [ ] P -------- --- --- <br /> RockSize -------------------------------- <br /> I <br /> ----------------------- ---- <br /> Water Table Depth ------------------------------------------------ - . <br /> ' -----foundation ----- Prop. Line -------------------_ <br /> Distance to nearest: We -------------- <br /> --------------- <br /> ­ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------•-------------) <br /> Septic Tank (Specify Requirements) ------ - ------------------------------------------------- <br /> - <br /> Disposal Field (Specify Requirements) <br /> ------------- <br /> -------- ---- - <br /> ------- <br /> � (Draw existing and required addition on reverse si e <br /> I 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- <br /> sed agents signature certifies the following: <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 /> as to become subiect to Workman's Compensation laws of California." <br /> Owner <br /> Signed ------ -------------------- --------- -- - <br /> -- -------- <br /> By - ------------- - - - - <br /> Title <br /> - - - - --------------- <br /> ---------------------- ------------------------- <br /> ----------- ------- - - - --- <br /> ` (If other than owner <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------ <br /> --------- ------------------------------. DATE -�_- `� ------------------ <br /> --- - - -- <br /> ------------------- <br /> BUILDING PERMIT ISSUED -"--- - ----------------------- -"---- --- <br /> ------------ <br /> ADDITIONALCOMMENTS ---- --; -- - -- - -- ----------- -------------------------------------------------------------------------- ----------------- <br /> -------------------------------------------- ---- ------ --- ---- <br /> ------ ------------------------ <br /> --------------11!------------------------------------ <br /> --------------------------------------------- <br /> - Date ---- -- -- <br /> - ----------- - ------ <br /> Final Inspection by: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r w 0 1-'AS Rev. 5M <br />