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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ..................... <br /> ••...... . . ...................................... This Permit Expires 1 Year From Date Issued Date Issued ..��.__. .....6 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION �l(J ' <br /> .-___•_•_ -___. 4..)-CENSUS TRACT <br /> Owner's Name ......... <br /> �-':� _ � ._. Phone <br /> Address ... _-_� -- <br /> _ <br /> / .._..._..-•-_. City _.. -t:F�-_- <br /> Contractor's Name __.___.. ._. .___ License Phone .............. <br /> Installation will serve: Residence ❑Apartment Horseflommercial❑Trailer Court 0 <br /> Motel ❑Other 1 %r- :b_c ' <br /> Number of living units:------------ Number of bedrooms ............Garbage Grirzder .._. Lot Size .................... <br /> Water Supply: Public System and name _..______ 4 Private ❑ <br /> ---•--•----------_..._.._•--•- .................. ............ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Cloy Loam ❑ <br /> Hardpan ❑ Adobe q Fill Material ............ If yes, type ............... ............ <br /> (Plot 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 f ] SEPTIC TANK FSize._-> ..?5. --. _._- _ Liquid Depth <br /> ............. <br /> Capacity �------t _L__ Type 1��'--r'- ______ Material__.? : .- No. Compartments .._ .......... O <br /> Distance to nearest: Well ------------------------------------ <br /> Foundation .... ................. Prop. Line ...._s.............. <br /> ....�-- --_----. O <br /> LEACHING LINE No. of Lines ...._....1_.____..-- Length of each line..----- !._�_..._.._-. Total Length .__.u? ................. <br /> 'D' Box __ -------- Type Filter Material ._ __ ______---Depth Filter Material ......../9.. _......................... <br /> Distance to nearest: Well ________________________ Foundation ..__l.Q--. ...... Property Line .- ._.....: <br /> .......... <br /> SEEPAGE PIT Depth ...,7,)--------- Diameter __ 5.._... Number ._.__--_�-................ Rock Filled Yes No 0 <br /> /f <br /> Water Table Depth ------------------------------------------------Rock Size -d7---V--X- J�_ f <br /> Distance to nearest: Well ----------------------------------------Foundation ..___ ._17: ........ Prop. Line ...�_________-____ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date .................................. <br /> SepticTank (Specify Requirements) -------------------------------------------_................................- --...........................•............................ <br /> DisposalField (Specify Requirements) ---•--•-----•--•----------------------------•----------•---•-----------•----•---------------------•-----------•-------•-----•--_----- <br /> ---- --- -- ------ -- --- ---- --------- --- -------- •--•-•-•------------•--------•-•----•----•-•---•----•-----•---•-----•---••-•-••-•--•-••-------------------•----•-•---------•--.._...--•-- <br /> -- - ------- - --------------- ------ ------------- ----------------------------------------••-........................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed _-. _ __ Owner <br /> BY --- ----- -- Title <br /> f ---•------------ <br /> (if other thorye wnerl <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ---••-•---•-----•---.... DATE ...7 . <br /> BUILDING PERMIT ISSUED . --- --- ____ D E _.. <br /> ADDITIONAL COMMENTS ..�.8-(�. d. �--�.� �� ---•--.....-� -•-- .1.�. 9J Q Y --•-- <br /> --- -----------------•--------------- -------•-•--.....................-•.........................-................................................ ................................................... <br /> ­--------------------­-- ------ ----------- -- - -------••----•-----•-------------------------•---------•--•---•------------------- --------------•••----•---•----•----------•---------- <br /> �- - <br /> Final Inspection b .........................Date ......_. ... . <br /> EH 13 21.E 1-613 v. S SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M <br />