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rvx urrii-c vzc APPLICATION FOW SANITATION PERMIT <br /> 7� -�3S <br /> .. Permit No. <br /> (Complele in Triplicate) <br /> .... ............................................-..... <br /> ,. <br /> Date !sued <br /> This Penult Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to contstrutf and install the work herein <br /> described. This application is made In compliance with CourAvprdinance No. S4 and existing Rules and Regulatlonsr <br /> JOB ADDRESS/LOCATION .. 7. ...f .._..... .... ......... ...-_..............................CENSUS TRACT .......................... <br /> Owner's Name - '_ .. .... ................................... . ............ .. ......_Phone .............. <br /> Address ---- <br /> .. ............ <br /> City �� 7.............................................................. <br /> _ <br /> Contractor's Name --- ..... .......................................License #4,R!_1 ---- Phone <br /> !nstallation will serVeh- Residence❑Apartment House 0 Commercial❑Trailer Court ❑ <br /> Motel Other <br /> t <br /> Number of living units:--- --_ Number of bedrooms ---E__.Garbage Grinder Lot Size ........................ <br /> ---- <br /> Water Supply: Public System and name ..................................___------------------....._..-----•--..................--•....------.Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam` <br /> Hardpan ❑ Adobe❑ Fill Material ............If yes,type............... ............ <br /> !Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer Is available within 200 feet,) �• <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size................................................ Liquid Depth ....................... .. <br /> Capacity .................... Type .................... Material...................... No. Compartments __........ <br /> Distance to nearest: Well ..Foundation Prop. Line <br /> I.EACHING LINE [ ) No. of lines ------------------------ Length of each line............................. Total Length ............................ <br /> 'D' Sox ............ Type Filter Material ....................Depth Filter Material ......................................... <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ....................... <br /> SEEPAGE PIT [ ) Depth Diameter ................ Number ............................ Rock Filled Yes ❑ No <br /> WaterTable Depth ................................................Rock Size ................................ <br /> 40 <br /> Distance to nearest: Well ........................................foundation .................... Prop. line .................. <br /> REPAIR/ADDITION(Prov. Sanitation Permit --. Date .................................. <br /> Septic Tank )Specify Requirements) ------ .. . . ...... ... .............L ............. <br /> Disposal Field (Specify Requirements) ....................................... <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 actordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or ilcen- <br /> sed agents signature certifies the fotlowing: <br /> "I certify that lin the performance of the work for which this permit is Issued, I shall not employ any person In such manner <br /> as to beco s bj # to War n`s en ensatlon laws of California." <br /> fined �_.._.._,--•_.. . Owner <br /> r.._.._... <br /> By ..... .... .............................Inerdl <br /> -...----•----. .Title ........ ..................................................... <br /> (If other than <br /> FOR DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED SY ..... :..._ .. . .................................................... DATE _. . ....:..........:-. <br /> BUILDING PERMIT ISSUED .............................. ..............DATE--:..-...................................... <br /> ADDITIONALCOMMENTS ................................................................................. ....._._.....__. ...._.....---........_........----..-......._..-.-......... <br /> ............. ............ ...... .................. .... <br /> .---..._. _..... <br /> - --- ------ ---------- •._.....-. .. - ..._..._-....... <br /> Final Inspection b Date . .. ...-. .' ............... <br /> P Y= <br /> ER 13 24 1-60 Rev. 5�i SAN 0 UIN LOCAL HEALTH DISTRICT 8/74 3M <br />