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FOR 6 FICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> �.._._.....j S- � <br /> ......... <br /> ....... Permit N�..--`-------._.... <br /> (Complete In Triplicate( <br /> This Permit Expires 'I 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 /> describers. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB A©DRESS/LOCATION}} .._ -__(�...... <br /> ,.-.L-:,P 2 NSUS TRACT <br /> Owner's Name ------------• f_�/f.... _... � �!/J_l._. f `.. ..:................ :................Phone ....__.. ... ...... <br /> Address _._...----ra. .«A,'err• .......City .......... ............. ._....... <br /> Contractor's Name ---------- License _J..l..� ,1 Phone --_-�-•- /..•• <br /> ,Installation will serve: Residence partment House J] Commercial OTrailer Court 0 <br /> 1. Motel ❑Other............ .............................. ��}} <br /> Number of living units _._.. <br /> : /.__ Number of bedrooms --- -Garbage Grinder . .... Lot Size C�-_SX . �....... <br /> Water Supply: Public System and name ........................................................--. ..._................._..._._..................Private <br /> Character of soil too depth of 3 feet: SandE1 Silt Q Clay Peat Q Sandy Loom ❑ Gay Loam ❑ �y <br /> Hardpan C) Adobe EJ Fill Material 41a if yes,type <br /> (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse slde.l� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer Is available within 200 feet) / <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC Size.-_-- �J� 4------•--_ --- Liquid Depth .s ................... <br /> Capacityd .------ Type _- t Ia#erial��No. Compartments . <br /> Ili <br /> nce to nearest. Well ....._......................Foundation ./0._.......... Prop. Lina ..�Z......... t <br /> LEACHING LINE No. of � Length of each line.._� �._�.......:...... Total Length .1-- ................... <br /> . <br /> 'D' Box <br /> --. Type .Filter Material 4.,k. <br /> ....Depth Filter Materia( /V./... <br /> nt to nearest: We .•, - ---.._ Foundation _.. d.._........... Property Line - 1........... <br /> SEEPAGE AIT Depth ...o? !---- Diameter _��. Number ------.,—?............. {tock Filled Yes �o 0 " <br /> Water Table Depth _...---- ,69SI..................._-Rock Size .....,1 <br /> Distance to nearest: Well �.�-----------------Foundation ,/.�.�...... Prop. Line -----— <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................i <br /> Septic Tank (Specify Requirements[ ......................................... -•--•-------......------•-•-•------- - ................... ....................... <br /> Disposat Field (Specify Requirementsi ---.............. --------- ---------.........---.... <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 Lawns, and Rules and Regulations of the San Joaquin Local Health:Dlstrict. Home owner or Iicen. <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 -4NACCEPTED <br /> Owner <br /> BY _ <br /> ._.... -� <br /> than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICABY - DATE .. - <br /> BUILDING PERMIT ISSUED _ -- - - -----= ------ -----DATE _ `. ._ .. . ..... <br /> ADDITIONALCOMM NT ---- ---- ----------•-••------•---•---••-----•---•---...-----...-----...._...-•.................................................................... <br /> .. ---------------• ------• _------•-_•----..-----•-----.._.__----------------------------- •- ---• ................ <br /> - <br /> ----------•-•-------------- --------------- <br /> Final Inspection by- -------- - - ----• ------ Date ..... _.-� .. <br /> --------- ------- <br /> EH <br /> 13 22t 1»6l3 N J AQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> l!a'' <br />