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FOR OFFICE USE:---.. APPLICATION FOR SANITATION PERMIT <br />.................................. Permit.No. .. ..................' . t <br /> . . (Complete In Triplicate) r <br /> _.................................................... Date Issued ..... . .. . 1 <br /> ........ .. ... ........ This Permit Ei:pires.1 Year From Daft Issued 3 <br /> Application Is hereby made to the Son Joaquin Local Health District for a permit to construct and Install the work eteln <br /> described. This application is made In compliance with CountyOrdinanceN . 549 and existing Rules and Regutations: <br /> JOB ADDRESS/LOCATION .ff?, .'71? ......... F..` ..................... CENSUS TR/4G'E <br /> Owner's Name ......... .................. Phone k�:7:�r� z <br /> Address '. .-�.�--. * — .� _..City -.....l�r.�s.-� ..��...... �`-- <br /> Contractor's Name . �� 4sidAencce <br /> ...............................................License # . ��ka-Phone . 1.. �' <br /> f/ <br /> Installation will serves ❑Apartment house❑ Commercial❑Trailer Court ❑ <br /> Motel❑Other <br /> Number of living units:............ Number of bedrooms ...rte_..----Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name ................................... ...............................r...........................................Private <br /> Character of soil to a depth of 3 feet: Sand] ,Silt❑ Clay ❑ Peat❑ Sandy Loam o Clay Loam❑ <br /> Hardpan® Adobe❑ Fill Material ............ If yes,type............... ............ } } <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. moat be placed an reverse alae.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if ublic sewer is available within 200 feet) <br /> 1 <br /> PACKAGE TREATMENT { ] SEPTIC TANK{ j Size._. . �1.. ... ................ liquid Depth .Jl....................... <br /> Capacity - :f'...... Type . Material---------------------- No. Compartments ..2-.............. t <br /> Distance to nearest.• Well ....................................Foundation Prop. Line _ <br /> } <br /> LEACHING LINE { 'j Na. of Lines .5.............:..... Length of each (Ino-74./ <br /> .... Total Length ..........................da62& <br /> D` Box ... ....... Type Filter Material ... ......... .....Depth filter Material ... .....---. -... <br /> . 6 ' <br /> s <br /> Distance to nearest: Well ........................ Foundation ......................... Property Line ........................f <br /> SEEPAGE PIT [ ) Depth ... Diameter Number ................... Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ................................................Rock Size ...._.._. .................... <br /> Distance to nearest: Well ........................................Foundation ------ .............. Prop. Line ..........-............ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ............................................. Date ............................ <br /> SepticTank {Specify Requirements) ---•..................................... ........................---..................---............._.........._................... <br /> DisposalField !Specify Requirements) ...........:...................................................................................................................... . <br /> ..........................................................................-.........••---•--.....................---.......----.......---....------......................--..............................r <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 Ilcem <br /> sed agents signature certifies the following: <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 California." <br /> Signed .................................................. ............................................... Owner <br /> `'•.'. �.. .e. .................................................. <br /> Title ... . ............................................. ......... <br /> By oer <br /> FCACiiPARTMSE ONLY <br /> APPLICATION ACCEPTED BY .._. .. .. _.. .... ..... .. ........................... ... .•----•---.. ..................... DATE ., <br /> ~..�. :...: .:.. <br /> I - <br /> BUILDING PERMIT ISSUED ......DATE .............................. <br /> ADDITIONALCOMMENTS........................................I.................... - ....................................:..:..................................................... <br /> ................... ............... .... ........... 1......... ... _-----....._..... ...._.._ ...... •.............- ": .._...... <br /> _ .. . .- . <br /> final Inspection by: ................... . .._..._.. .._ ..._...................Date ... ...-M <br /> EH 13 24 1"68 lay. 5i SAN JOAQUIN LOCAL HEALT DISTRICT 8/7b 3H <br />