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FOP OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> • • • Permit hlo: -•I•�• ......... <br /> (Complete to Triplicate) - <br /> ------ - •--------- •...................... ------ <br /> Date Issued <br /> - -. ------- ------..............•----•----•___-- ` This Permit`Expires I Year From bate Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Mules and Regulations: <br /> JflB ADDRESS/LOC ION -_._�� _��_. ... f --• ----•---••--------------•----•--CENSUS TRACT ---.- <br /> Owner`s Name -- .. ._..--•----------- ------------- -..----Phone ----------------------._... <br /> Address _- � .- - -- ------ City -�-��------------------------- ----------------•---------- <br /> Contractor's Name <br /> ------------- ------------------------ '' License # /213 Phone ......... F <br /> ------ <br /> Installation will serve: Reside e❑Apartrrient House❑ Comme al❑TroiI Court ❑ <br /> �L 2_ <br /> 1Vlote! ❑Other :_ '�'�-V-- ----____-- <br /> Number of living units------ ---- Number of bedrooms . 2--.-Garboge Grinder ._--_._-_-.. Lot Size ---------- <br /> Water Supply: Public System and name -------------------- ------- __---------------------• ----••-•-•--------------------• . •.._.Private [N <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam;f Clay Loam 0 i <br /> Hardpan ❑ Adobe oI Fill Materia} If yes,type_.....---.....__.__....._... <br /> • r <br /> (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepagepit permitted if public sewer 1" available w€thin 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK Size_ --/.f-.•-�••-------------- Liquid Depth <br /> 1 - _ ---------- <br /> Capacity lJ Type �1 -_ Material <br /> -� - --- N=,. Compartments „-r.----:- <br /> Distance to nearest: Well --------- -- -------------Foundation ____ - --------- Prop. Line ----- - _ <br /> i <br /> i <br /> LEACHING LINE [ J No. of Lines ------ -------------!Length of Qch 'line........... <br /> _-.-. -.-ZO'----_--.Total Length --_ t-- -.--.----.-- <br /> _ k <br /> D' Bax ___-------- Type Falter Material ---•-��. ------Depth Filter Material ------- _ ____�f_________-- ---•-.------- <br /> { i <br /> r Distance to nearest: Well ______-��--r-_-- Foundation -____--�� -�-��-_-- Property tine --- ---------------# <br /> SEEPAGE PIT j Depth -------------------- Diameter _-• ------------ Number ---------------------------- Rock Filled Yes ❑ No l0 <br /> F <br /> Water Table Depth ------- ---------------------------------------Rock Size - - ----------------------- <br /> Distance tv nearest: Well .......___----------------------_--------Foundation - ------------ Prop. Line .---._.._-___.._._..-- <br /> k <br /> REPAIR/ADDITION IPrev. Sanitation Permit# -------------------------------------------- Date ------------.---------------------I <br /> Septic Tank (Specify Requirements) -----••------------------------------------- ----• ---- - ------...-- ----•- ------- -- •--------•---------------------- --- <br /> Disposal Field (Specify Requirements) ................ ---- - - ----------------- -- ----------------------------------- <br /> ...............•..-.. ....- •--- ---------- --------------------------------------------------- -------- ------------------....................... <br /> _._.._._..._ <br /> --- ----------------- •-••-------••...•--•--...............•--..... _ _........... <br /> F (Draw existing and required addition on reverse side) <br /> I hereby certify that l have pro fared this application and that the work will be done in accordance with Son Joaguis <br /> County Ordinances, State Laws,':and Rules and Regulations of the. San:-,loaquin Local Health District. Home owner or licen,L <br /> sed agents signature certifies the following: . <br /> "I certify that in the perforrnance of the work for which this permit is issued, I shall'not'employ any person in such manner <br /> as to become subject to m 'n's Compensation laws of California." <br /> Signed ------------------------- ---------- --------------s -—Owner– <br /> By <br /> wner ._. i <br /> .1 <br /> By_.......--------•------ ---------- --------- ' Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED_BY - _ <br /> _-_ '4_ _ .,.- ----------------------------------- DATE -5p-`_ <br /> BUILDING PERMIT ISSUED ---- •�- AT� <br /> �-D ."�_ �............... -----V......- <br /> ADDITIONALCOMMENTS ------------------------•- ----------... = --------------------..................---------------------------------------------r_.......... <br /> •_-... _.--._.--- - .--- __•- -------_------4 �n_- •..... -_•. -.. ......... .............. ...••-____- _ ___..._ <br /> --------------.... ----- ------ -.. -------------- ___------------------------------------ -------- <br /> _...-.. <br /> Final inspection by: --------- •---------------------------------- ---------------------Date --. r''i2.'. . • -.........-.4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r E. H. 9 1-'66 Rev. 5M <br />