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FOR OFFICE USE: <br /> a APPLICATION FOR SANITATION PERMIT <br /> --•-•-----4............................................. <br /> (Complete in Triplicate) Permit No. .7...` �L <br /> ......................................................... This Permlr Expires I Year From Doh Issued Date Issued ` . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to eonstreict and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION`.._.( .--.. ._-G!• �G! ...............L� G�..........•............CENSUS TRACT ......... <br /> .-.-....--......_ <br /> Owner's Nome ... .-_-... ls.1 C�I�.- .._.. ...,.Phone ......-. .. <br /> Address ... ---&,c-o-._e,-.. .. .. ............ ............... City <br /> Contractor's Nome �• -------- ---------------- -_-._...............................License # ........................ Phone •---••------•-- --•--- <br /> Installation will serve: Residence r ment House❑ 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 d Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan Ej Adobe E) Fill Material ............ 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: INo septic tank or seepage pit permitted,If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] Size----------------------......................... Liquid Depth .......................... <br /> Capacity .. ------ ------- Type --------- ---------- Material.--------------------- No. Compartments ...................... <br /> Distance to nearest: Well -------------------------------- -Foundation ----- ................ Prop. Line ...................... <br /> r <br /> LEACHING LINE [ j No. of Lines --------- ------ Length of each line............................ Total length .y.7 <br /> I <br /> 'D' Box ...._._. --- Type Filter Material ____________________Depth Filter Material ............................................1" <br /> Distance to nearest: Well .........................Foundation. ---.................... Property Line ........................00 <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter __-------------- Number ._.......................... Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth ----------------------------------- --------••--Rock Size •------------------....•-----•. <br /> �- s <br /> Distance to nearest: Well ........................----------------Foundation .................... Prop. Line ......... ............fl <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date --------.-------------------------} Y, <br /> Septic Tank (Specify Requirements) .............. ..•_.-_... ..----------------------_••.. <br /> Disposal Field (Specify Requirements) ____- -..--- ------ ......... ..............._. <br /> ---------------- <br /> _. :. <br /> ---•-------------------•- ----- ----------------------.------ ----•---------...--------------.-----......._.............._........ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance wish San Joaquin <br /> County Ordinances, State Laws, and Rules and )Regulations of the Son Joaquin local Health.District. Home"owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in theperformance of th work for which this permit is issued, I shale not employ any person in such manner <br /> as to becy <br /> sub' t man' X'n;zWii0pr�- <br /> enls fornia." <br /> Signed -- <br /> Owner <br /> BY --------- ------------------------• ----•-•---- ---------- Title --- -------- ---- <br /> (If other than owner) <br /> FOR DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- <br /> BUILDINGPERMIT ISSUED ---- --------------------------------------------•- --------------------------:--------------------------DATE .------- -----••------•-. ...... _ <br /> ADDITIONAL COMMENTS ..-- ------------ -------------------------- <br /> ---------- ------- -•----------------------------- <br /> ---------------- <br /> ------------------ ,-- --- ------ ...... . ..--------.... <br /> Final Inspection bY: -- ----- -------------•...---_----------------- --- ----..--------- Date _..�e�.' ... ........._ .- <br /> �3 2 -� �'� SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7Ei 3M <br />