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FOR'OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -7 <br /> ............. ----------_ Permit. No. <br /> (Complete in Triplicate) <br /> ..................................... <br /> Date Issued ...... <br /> ........................ This Permit Expires I Year From"Date Issued <br /> Frplicoti6n-is e_� the Son Joaquin Local Health Distr'ict for' a permit to construct and install the work herein <br /> A Uh? �rymode to . <br /> described. This appy <br /> vve tion is made in compliance with CountyOidinanc0 No.-§4�c xisting Rules and Regulations- <br /> JOB ADDRESS/LO dXTIt-'.—CENSUS TRACT <br /> _........ ..Ph. ..__,_ <br /> .. ...... ........... ................ <br /> Ph <br /> Cit <br /> ..........�; <br /> Address 7.............. ------ <br /> Owner's Name -or.. .. <br /> Contractor's ......... ........License # .. P...... h�on a <br /> Name - -- ------- . .............. <br /> Instollation will serve-- -Residencera F—im ent House 0 Commercial oTraller Court 0 <br /> Motel.0 Other ............ ..........L- .... .. <br /> Number of living units:_-..-..__,._77 Number of. b6droorri-s-_74 orbage Grinder ...........—Lot Size <br /> Water Supply: Public System and name ---........1111 --1111 ................ ---------- --••--------.--------•---.......__...: ............ Private <br /> Character of soil too depth of 3 feet:' Sand t] -SiltEl -Clay &_��Pot[] Sandy Loam -[3 .Clay Loam <br /> ❑ <br /> Hardpan Adobe ❑ Fill M6terial ............ If yes,type -.:............ ...... <br /> {Plot plan, showing size of lot, location of. system-.in',relcition. to wells, buildings, etc, must-be,placed on reverse side.) <br /> NEW INSTALLATION- (No septic tank or seepagepit permitted ermitted lfpy <br /> 'public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANk-J Size-........... ...... ............ -------- Liquid -Depth............................. <br /> Capacity ._...........:..--- Type ..................... Material.- ...---------------- No. Compartments ...................... .A <br /> Distance to nearest- Well ...............:....................Foundation ...................... Prop. Line ..................... <br /> e ine............. 9 <br /> LEACHING LINE No. of Line ....................... Lengthof ......... Total Length ....--•...........__...._... <br /> V Box ............. Type Filter Material ...s:.----••-......:D epth Filter Material ....................... ....... <br /> Distance to nearest- Well Foundation ------------__.... Property Line ................... <br /> SEEPAGE PIT Depth ............ Diameter .............. Number ...................4........ Rock Filled Yes ❑ No <br /> ❑ <br /> • Water Table Depth...... ------- ............... ........Rock Size ............ .......... <br /> ................ <br /> Pro line <br /> Distance to neo ........Foundation. <br /> rest. Well-....-------- _r........:---- -- <br /> p. <br /> REPAIR/ADDITION(Prev. Sanitation-Permit# ....--••--------------•........r............. Date .:_._................_._..........I <br /> Septic Tank (Specify Requirements) ................... .. .......................... ........................ W. <br /> - ----------- <br /> Disposal Fiel�' (Specify Requirements) . . ....... ..... <br /> .........._.............. <br /> --------------------------------------------------------------------------------r---------------- -----------------*---------------- <br /> . ...................................11- <br /> ---------------­.................­..................................­­------------ ..............................I............................... <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.-Horne owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work'for which this permit is iisued, is'hall not employ any person in such manner <br /> as to become subject to Workman's Cornoens6tibii'laiws'of'Cd"lifidrkilci <br /> Signed ...... ----- ---- ------ ---I.....-- ............. <br /> ...................... <br /> .... <br /> Owner <br /> Title -----By ....... . ................ <br /> ....... ... . .....A.. . -..... . <br /> (I other thowner) - <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .._..1111------------ ----=---------------•-•-•---I..... ............. ....... .... DATE .... ...... <br /> .............I...... <br /> BUILDING PERMIT ISSUED ............. .......... ........DATE ------- <br /> . <br /> ADDITIONALCOMMENTS ........._.:.................................... ------------------------- ......................................................................................... <br /> --------­------ ..........................I....... ................................*...................... ............ ......................................I...... ............................ <br /> ............ ..................... .................... ...........;­.............. ............... ........... .............. .................................. ..... ----------------- <br /> fi <br /> ............­­.......I................ ........... ..............................••--•...;. ................................... ........ .. .. ............ <br /> ...... 09 <br /> ..................Dote .-_.. <br /> Final Inspection by. ................ ...ed;----------- ...... .................... ............. <br /> SAN JOAQUIN LOCAL'.'HEALTH DISTRiCT <br /> Ce <br /> 7/723 M <br /> F_ H-_1-3 24 1268 Rev. 5M <br />