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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ................................................ <br /> 4Complete in Triplicate) Permit No: <br /> ThisPermit Expires i Year From Date Issued Date issued <br /> pplication: is hereby made to the San Joaquin Lacai Health District for a permit to construct and, install the work herein <br /> described. This application,is.made in compl ce with County Or ' ante Na. 54 and existing Rules and Regulations: <br /> JOB ADDIZESSAOCATi N �. � - - ---- -- - ---- .:� --•--CENSUS TRACT .------------••-----�1_ „% <br /> Owner's Name .--•--- C� � _ . 3t�ct .-- Phone �r <br /> Address --_------_---��� mi- <br /> Installation <br /> -- ------ ------------------------City - - <br /> • -- - ---Contractor's Name ...•-.--•-.... ..- -- -0__..... _..__._- License # ZOV4. _.r._... Phone will serve: Residence❑Apartment House.❑ Commercial❑Trailer Court ❑ <br /> Motel ❑Other-------------------------------------------- i <br /> Number of living units------------- Number of bedrooms ------....Garbage Grinder ------------- Lot Size -----.---.--_____•--__--__--___:___-___----_ <br /> Water Supply: Public System and name ................-----------.----------------------------.__........_.:------------ ......_..._ .__._..__....Private <br /> Character of soil to a depth of 3 feet; Sand 0 Silt[I Clay Cl Peat Cl , Sandy Loam IX Cloy-loam.g i <br /> Hardpan E] ' Adobe 0 Fill Material ............If yes,type___.-_____________________ <br /> (Piot 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 seepage pit permitted if public sewer'is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK ize----------- quid .Depth _, ---.-_--•-..._�. <br /> --- Li <br /> �______ Material��._`.---_ No. Compartments --------- <br /> Prop. <br /> Capacity - Type. - ------- ---• -- P - - -.._ ..-•--z•--- <br /> Distance to nearest. Well ___.___ Q�f................Fousrdation IQ_�f'.._. Prop. line <br /> LEACHING LINE ( No. of Lines --_--__�-.__-_.___ Length of each line-------(0©_ ......... Total Length ..l Q.. ........... ` <br /> 'D' Box ... Type Filter Material .4 ... _ _-.Depth Filter Material ... -------------0L <br /> ---- -- <br /> Distance to nearest. Well _.___�0 ..._ Foundation -------AIA 1 ._-- Property Line ........f''..._....... <br /> SEEPAGE PIT [ I Depth .------ ------ Diameter ----........... Number ____________________________ Rock Filled Yes ❑ No 0 <br /> Water Table Depth --------------- -•••-•---•-- ...................Rock Size ................................ <br /> Distance to nearest: Well _.............................•..-------Foundation .................... Prop. Line ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------} <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------•-•----•-------------- ----------------.,!.......................... <br /> Disposal Field (Specify Requirements) ---•---------•----...---•-•---------------------------------- --------•- -----_-----------•---•--••---•--•--------- <br /> ------------------•-•••-----------•-•-------•-- --------- ---------------- ----•---------------------------------------------•-------------..............--•............................... <br /> IDraw 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.Home owner or licen- <br /> sed agents signature certifies the following.- <br /> "I <br /> ollowing:"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,Compensatian laws of California." <br /> Signed ------= ----------- Owner <br /> ---------- ------ --- <br /> ------ Yitle <br /> -----•----------- ............ <br /> BY <br /> if er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY..... . -- -.-=•-L%.___-•- ....... DATE .... ............. <br /> BUILDINGPERMIT ISSUED ----------•---•-----•-----------•-- ----------------------------------•-------------------•---------•-•--DATE -------•--.. ---------------_-_------- <br /> _-. <br /> )ADDITIONAL COMMENTS --------------------------------------------- ----•--------I----------------•----- --- <br /> ...................................................... --- •--•-----•-•. ............. <br /> Final Inspection by: ._ { --------------------------------- -------------- Date <br /> a; - ..... y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />