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�S <br /> FOR OFFICE USE: APPLICATION'FAR SANITATION PERMIT <br /> r, <br /> Permit No. ....... -..........J. <br /> f (Complete in Triplicate) <br /> ........................................... This Permit Expires 1 Year From Date Issued <br /> Date Issued .7`............:. <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, 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO ' l!.. . . .................................:.........CENSUS TRACT ....................... <br /> Owner's Name ................•••-_. W Phone <br /> :... . <br /> Address ...._...... � r.l , .. ... ... .... ........ City.............. ............. ----------- ----- ..-*............... <br /> Contractor's Nam�e ... .......license # YPhone .._.... -..-.-.---...._ ........ <br /> f <br /> Installation will serve: Residence [] Apartme�Io 0 Commercial Trailer Court 0 <br /> Motel ❑ Other <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder .._...._.... Lot Size ........................... <br /> Water Supply: Public System and name .............-.......................................................... ...........................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ -Silt❑ Clay ❑ Peat❑ Sandy loom P511, Clay Loam ❑ <br /> Hardpan ❑ Adobe.[3 Fill Material ....... .... If yes,type ____________________________ <br /> (Plot plan, showing size of lot, location ofsystem 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 I ] Size.....................___..................-- liquid Depth _....------............... � <br /> Capacity _____________ Type .. Material...................... No. Compartments r <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ....:................. 0 <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 0;] <br /> 1 <br /> Water Table Depth ........... ..........Rock Size ... , I <br /> Distance to nearest: Well ........................................Foundation .................... Prop. line .................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..._.......... ................. <br /> Septic Tank (Specify Requirements) � <br /> Disposal Field (Specify Requirements) <�.1 - 1___._ ..._ ..... <br /> IV <br /> --- = <br /> -----------------•-••----...._.---I...... -----..... - ................ ------------------------I...................... <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 liven. " <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit Is issued, t shall not employ any person in such manner <br /> as to become" bl ct to Workman's Compensation laws of California. <br /> Signed ...... ....... G ... _..... ................................ Owner <br /> BY -•-•------ ......... -•-- •. _. - .......................... ••- Title . c-aJ._...:...__.......... <br /> (If other than owner) f! <br /> FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ... .':�`f..7................... <br /> BUILDINGPERMIT ISSUED ............................. ........­...... -----.::..._..----•---••---------•---•----------=---DATE _.......................................... <br /> ADDITIONAL COMMENTS ..................................................................................------..............:_....__._..._................................... <br /> ....... <br /> ..................... ....... .____.____._____....:...........____._._.............-::._.._ _ _. <br /> .. .... .. ..... .. <br /> Final Inspection by: .. Date . -` . <br /> SAN JOAQUINLOCAL HEALTH DISTRICT C <br /> a u 1-3 24 1 .ten n_-. r►i �/`�� 7171 'A ,M <br />