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FOR OFFICE: USE: APPLICATION FOR SANITATION PERMIT <br />....................................................... (Cantplsts In Triplicate) Permit No. .Z :S S� <br /> ...................................................... This Permit Expires 1 Year From Date Issued Date issued . ��` ... s <br /> i <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to construct and install'the work 'heroin <br /> described. This application Is made In compliance w4COty Ordinance No. 549 and existing Rules and Regulatlons: <br /> JOB ADDRESS/LOCATI ..-..�7.j�..� -?.. .... ....... .................................CENSUS TRACT .......................... <br /> Owner's Name 4" .... .................. .......................................Phone .................................... <br /> Address .... s ................City ... .......... ......... .... .. • <br /> Contractor': Name ..- - --+--._ A .............Cleanse Phone <br /> Installation will serve: R earca .Apartment Hausa ] Commercial❑Trailer Court ❑ <br /> i <br /> Motel ❑Other............................................ <br /> Number of living units:------------ Number of bedrooms _Garboge Grinder ------------ Lot Size •-----------------------------•------- <br /> Water Supply: Public System and name -----------_---- -----•-- ....--._..........--------____--.........................------...........PrP� <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ day 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 :ido.10 <br /> NEW INSTALLATION: IN* septic tank or seepage pit permitted If public sewer.is available within 200 feet,) <br /> PACKAGE TREATMENT ( 3 SEPTIC TANK f ) J Size........._.................................... Liquid Depth ........................ <br /> Capacity 1 &....... Type - .......` '. Material...................... No. Compartments '._........ <br /> Distance to nearest: Well Aa......................Foundation .�. ............. Prop. Lina.... <br /> _. .......... ... .. <br /> LEACHING LINE { D No. of Lines .................. Length of fach line....7 ................ Total Length_ ..�f��. .---......... <br /> + 'D' Box .r_---.__ Type Filter Material . ... ..Depth filter Material .°�-.... ...............---- -•_•• <br /> . , Distance to nearest: Well ........................ foundation ........................ Property Line ...•............ .. <br /> SEEPAGE PIT O Depth -------------------- Diameter ................ Number ........................... Rock filled Yes ❑ No ❑ <br /> Water Table Depth ................................................Rock Size _.._.........:................... <br /> Distance to nearest: Well ........................................Foundation -_-.._.. ........... Prop. Line ......... r' <br /> REPAIR ADDITION Prev. Sanitation Permit .... Date l ` <br /> SepticTank (Specify Requirementsl ......................................... ...........................................................-.............__................ <br /> Disposal Field (Specify Requirements) ................................................... ..................................................... .................... <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, Stats Laws, and Rules and Regulations of the San Joaquin Local Health District.Henke owner or Idcsh>,- <br /> sW agents signature certifies the following: <br /> "1 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 su (ect to W rkman's Co pensation laws of California" <br /> .Signed . 1-•---- -------------------------------------------------_ owner <br /> By ............................. .• .._.. -------- yitte --- <br /> If other than owned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ...... ................................ DATE..C...:.�'.�.�........... <br /> BUILDINGPERMIT ISSUED ....---•.............:...........................•------•-----•---..-......--.. .....-...--•---=-_---....DATE ...:.-....-.-.__................-.......... <br /> ADDITIONAL COMMENTS .._. .....................:........................... <br /> ................................................ .... -------.....--- ---.. ...............................................-......................... <br /> ._.-...-..-............. <br /> ................................ .... .-. _ .- . -...----......... .......-.. <br /> ... y <br /> final Inspection by ......... ....Date -- :.r �Z ......._... <br /> EH 13 21h 1-6 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />