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s <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .- " &/ 1 1 <br /> Permit No. ! <br /> {Complete in Triplicate) <br /> ---•.. ............................ <br /> ....._A——....._• .•..... This Permit Expires f Year From Date Issued 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/LOCATI N ....� :©' .. .....................................CENSUS TRACT --------- ---_---------- <br /> ..Name ..... �...... _ . r �-:. ... ......... . __.... Phone <br /> .. <br /> rs �Z .. CitYAddress ........ .. . . - <br /> . ... <br /> / Phone/ �+•_, ..C�-- <br /> Contractor's Name <br /> installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other ........ ............... ....... ----•---•-- <br /> � V <br /> Number of living units:....1_.._ Number of bedrooms _ -----Garb a e Grinder- lot size 0----/�. ..... <br /> • <br /> ..Private <br /> Water Supply: Public System and name .../,) va ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Ha ❑ Adobe pT, Fill Material ....-....-.. If yes,type .......... ................ <br /> {Plot plan, showing size of lot, locution of.system in relation to wells, buildings, etc. must be placed on reverse side.)C I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT , [ ] SEPTIC TANK Size.. .� �.` �-�-- ..._ Liquid Depth ... ................. <br /> Capacity/lov.C'.Ze- Type Arl Material. - No. Compartments ..�:.............. <br /> Distance to nearest. Well `'.-w„[-.eY._........Foundation -le-------------- Prop. Line ........ <br /> LEACHING LINENo. of Lines .__ _. _ Length of each line ../aa-- -- ------ Total Length .,�(!�..�__......... <br /> .. ./ "''Type,filter Material :=_ `Depth-Filter.Material 7'.7.. :....-............... <br /> Distance to nearest: Well )Z4-A1_t& Foundation Property Line .......... <br /> f SEEPAGE PIT Depth Diameter -- Number ..... ................... Rock Filled Yes No <br /> Water Table Depth _... ....�.... ------ ------Rock Size _.. .�_......1----------- p i <br /> Distance to nearest: Well -:---------Foundation ...le____ ..... Prop. Line ..s�................ ; <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..------..._.----.--•-------------1 <br /> is <br /> 4 � <br /> Septic Tank (Specify Requirements) ..................... -•...... . ----------•--------•----. - • - --------------­--------- ................................. ...... <br /> Disposal Field ISpecify Requirements) --------------------- ----------------------------- ----------------- ----- ........ <br /> ............................ ------------------ ------- ....................... ................. ..........-................. ...... <br /> (Draw existing and required addition on reverse sidel <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 SorijJoaquiwlocal Health.District. Home owner or licen. <br /> C sed agents signature certifies the following: i r <br /> "I certify that in the performance of thewark for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensations laws of California." ' <br /> Signed .:_... <br /> . <br /> ..--- -- "------------ :... Owner <br /> By ._ .. .. .... Title .. ?.... .....:...................... <br /> f other than owner) I <br /> —FOR y.DEPARTMENT U E-ONLY — --~`•-. _ _ - �-"`.' <br /> i APPLICATION ACCEPTED BY .... :._.. ... ... ........ DATE .'....... ._.y.... - <br /> BUILDINGPERMIT ISSUED ...._...-............................... ...........__..------._............._.. ..............DATE ..._..-- ............. <br /> ............. <br /> ........ .. ... ....... .. ... d �� Z..� . <br /> ADDI I AL <br /> t <br /> ...---•-------------------------- -- ... --------- <br /> AQUiN `LOCAL HEALTH DISTRICT it„� <br /> ` <br /> c u 13 24 1 -An os.. SAA 7/72 3 ,4L_ _ <br />