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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ...... _.f-c!�:?. .... Permit No. ..7,3`.3sF <br /> (Complete in Triplicate) <br /> ................................... This Permit Expires 1 Year From Date Issued 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 Ordinance No. 644 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ,:.�.j...77 �.._,: ##--�--.l�t. J .�.................................CENSUS TRACT .................. _ <br /> Owner's Name ...... .�. � . fit,. iNl`_._ _ ............. ... ........... l3hone .��/,.' .� ......._ <br /> / <br /> .. .............. <br /> Address - 21(, Ci ........................................... <br /> Contractor's Name -------------------- --------- --- -•- <br /> .............License #2 y.: J�Phoned s <br /> Installation will serve: Residence MApartment Mouse') Commercial ❑Trailer Court 0 <br /> Motel ❑Other ...................................... <br /> Number of living units....../---- Number.of bedraoms __'5...._Garbage Grinder ............ Lot Size ....!..Z ..` - .......... <br /> Water Supply: Public System and name .......:............. ....... ................. ---..........-................ --•---•------. -------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy loam ❑ 'Ciay Loam <br /> T . <br /> Hardpan ❑ . Adobe 1K Fill Material _...''':.:..-If yes,type --r`:....................... <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 sewer is available within 200 feet,) <br /> PACKAGE TREATMENT -[ }-., SEPTIC TANK[ ] -<r - .Size:..._.:.:........................:........... Liquid-Depth .......................... � <br /> . Material................. No. Compartments <br /> Capacity -------------------- Type .................. ----- ...................... <br /> Distance to nearest: Well .......... ........................Foundation ........................ Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------------------- Length of each line--------------.__--......... Total :length ............................ �( <br /> 'D' Box ............. Type Filter Material ....................Depth Filter Material ...................-_..._--------:...__-- _ - -- <br /> Distance to nearest: Well ........................ Foundation.---.............................. Property Line ..... ................ <br /> SEEPAGE PIT [ } Depth .................... . Diameter ................ Number ........................ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ...Rock Size I ' <br /> Distance to nearest: Well ........................................Foundation --- ................ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# <br /> .. --------------------------------•---- Date .......................-- ........ <br /> SepticTank (Specify Requirements) ....................................... ....•..........---------------------------.......................................------------------ <br /> Disposal Field (Specify Requirements) ._ .._.. ----------- -- <br /> ---- ------ -••---. - ... <br /> • <br /> r 33 , z 5 � 'c.� .. ----- <br /> ------------------------------------------------ --------- --- .x----- <br /> ..._.:._Y ......----....._ •-•------------•..........-•-------------------------------- <br /> ----..--._---------------- ....... _._ <br /> `(Draw existing and required addition on reverse side) <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: k <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 Califorriid." <br /> Signed .......... .............. . ........ :..... .................... . Owner <br /> By .._......._ c...... ............................. . Title .... ............ •-----.._.... <br /> (if of r t an owner) <br /> O DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY —_ ..... .. .. .. .................................................._........................ DATE .....ft�;r_ <br /> BUILDING PERMIT ISSUED .DATE �� �3 <br /> ADDITIONAL COMMENTS . ------..�..................-- _.. .....----...--•------- •--....... ......... <br /> .._.........._ <br /> ---------------•-•---...------------------..._........._._..------...._........_............_... �. <br /> ••---- ................•-• -.._..--------•-•-•---••---............--------•...--•••--------- .........1.............. <br /> .......................:...... _._._ .. .............---..__...------................--------- .............-•-••-. ---.......... <br /> •-- <br /> Final Inspection by: . -- ................. .. ...................•••-------........Date ___- <br /> 4-SAN <br /> -------5,,,.SAN OAQUIN LOCAL HEALTH DISTRICT <br /> 7112 3 A <br />