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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No �:., �'.°.. <br /> (Complete in Triplicate) <br /> •......................... p Date Issued .� <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby rri4de to the Sar►,Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application Is made in compllance with County Ordinance No. 544 and existing Rules and Regulationse F <br /> .�.: ........ <br /> .JOB-ADDRESSAOCAT . .. <br /> ...........................CENSUS TRACT ........... ... <br /> �, - -QQ, ( •Q Phone ` .. �4S.at... <br /> Owner's Name -----_.... - ...................... ........ <br /> f�ddress . .....- Z�7.._�3F �....... . ....................City .. ((_.._._......... .... ........................ <br /> r _ #a? 4...� r... Phone .!'.!?. ':.1.. �.!_.... <br /> Contractors Name _ .................... <br /> i <br /> �" ........ 4T' <br /> :.... C ry...... L cense <br /> Installation will seiveh . ] � ResIdence,WAp&rtmeAt-House 0 Commercial QTraile_r Court <br /> otel-01Nher.:.....................'.........._.... ...... <br /> - ----- -•----...... <br /> D 1t C... . <br /> Number of living units:.-1...... Number of-bedrooms Garbe a Grinder Lot Sias •-- --- .... ❑ <br /> '.�-t�..�. ......Private <br /> Water Supply: Public System and name `ter <br /> .....TM �. < . .._..._..�....... <br /> .. ... Clay Loam D <br /> Character of soil to a depth of 3 feet: ',Sand Q Silt Q Clay ❑ Peat Q Sandy Loam ❑ <br /> Hardpan❑ Adobe Fill Material .... !f yes,type............... ............ <br /> !Plot plays, showing size of tot, location of system In relation to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATIONt INo septic tank or seepage pit perrititted If public sewer-Is-available within 200 feet,) <br /> K,k„ ............. Liquid Depth <br /> PACKAGE TREATMENT [} SEPTIC TANK I ] 9 Sixe........................... ....... ... ... ........ <br /> Capacity .................... Type ....1 .... . Material....................._ No. Compartments ................... <br /> . <br /> Foundation .._ Prop. Line <br /> • Distance to nearest._ Well ..':.....----------------:.......... ....---...._....--- ...........,....... <br /> .EACHING LINE ( ] No. of Lines ......--•............... Length -of�ea&line............................ Total Length ........................ <br /> 'D' Box ............ Type Filter Material% .--.....Depth Filter Material ................................ .......... <br /> Distance to nearesh Well Y Foundation ........................ Property Line .....•• ......••• <br /> 7 `' -::........ Rock Filled Yes ❑ No <br /> SEEPAGE PIT Depth .....$.Diameter--:;. ......:::Number .:.:_....:::•... <br /> ( ] Water Table .Depth ................................................Rock Site ................................ <br /> 4 <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ..................... <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ........................ ................... .Date ................................ .] <br /> spilt Tank (Specify Requirements) ............ �...q . .r. •--••---•.....r .... .......... ».......................... <br /> encs .GfL.QG �, .. . -�'• _............................ <br /> Disoosal Field (Specify Requires 9 - <br /> ---------------•------.......-----.......------•----- '... .._.........._._....._...__.................._.........._. . <br /> ............................................................. ............._............................................................................................ <br /> (Draw existing and required addition on reverse sidel <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 th'e Son Joaquin,Local Health District. Home owner or licen- <br /> sed agents signature certifies the fallowing: <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 /> .anec' ............... Owners . <br /> ....... <br /> 4 ` ►..:... . <br /> Stitle .... .. <br /> ......... .......................................... <br /> By . .. .. ........ <br /> (If oth t an owner) <br /> FOlty DEPARTMENT USE ONLY <br /> ......................... ... <br /> APPLICATION ACCEPTED BY -..r. . .. ..... DATE <br /> �� _ •• -............DATE,,:.-. <br /> BUILDING PERMIT ISSUED <br /> .................. <br /> ADDITIONALCOMMENTS ....... ................-----------•-------- --••-----• ---•-----•-...................................... ..................... <br /> ...................... .I.....-... <br /> -------------------=............................._..........-......_. ..............-----.....--.... <br /> �- ............. _......... <br /> - : <br /> ......... ---- :.....:....:...:.. ... u <br /> ----...... .... ............ ... <br /> ,.. .... <br /> ..... . .......... ....• �----�- Date . .. ... .... -- �. ............ <br /> Final Inspection by: .. ... .. .... . ................................... _... �. ..... <br /> M 13 2h 1-•68 Rev'. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/?� 3l1 <br />