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FOR OFFICE !}5E: <br /> APPLICATION FOR SANITATION PERMIT <br /> Pe ���lzG <br /> (Complete In T licate) 'Per <br /> No. . .. .......... <br /> This Permit Expires DaM Issued Date issued ..�.r:�� <br /> Application is hereby made to the San Joaquin Local Health Dist ermit to construct and install the work herein <br /> described. This application is made in compliance with Cou549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAkN "-- --- ...: - -�.[�`{�-- _-. .. &..........CENSUS TRACT .......................... <br /> Owner's Name <br /> . .. Z .� .......Ph4on))e <br /> (� s / <br /> Address ... ............ .......... <br /> ''...... .. <br /> ...--------- <br /> Contractor's Name.,.. ........... - _ ..............LI �la _7�.. Phone . . <br /> Installation will serve: Residence Apartment House[] Commercial urt 0 <br /> Motel Q Other............................................ <br /> Number of living units:...-/_.... Number of bedrooms .../......Garbage Grinder ...... #ze <br /> Water Supply: Public System and name ......................................................................... <br /> ....Private <br /> ............. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Clay loam ❑ <br /> Hardpan❑ Adobe 2f Fill Material ............ If yes, <br /> (Plot plan, showing size of lot, location of system in relation to" wells, buildings, etc. mum. <br /> u - placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit ,permitted if public sewer is available'within 200 feet,) 1 <br /> PACKAGE <br /> GE TREATMENT [ ] SEPTIC TANK j Size..........................••---•.. ............. Liquid Depth ....•----- <br /> Capacity ---•---•----- ------ Type -•--•--•-------•-•-- Material...................... No. Compartments ...................... <br /> Distance. to nearest: Well ....................................Foundation ....---_-..---- __. Prop. Line ...................... a <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line-------------................ Total Length ... ........................ o <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ------............... ...................... kP <br /> Distance to nearest: Well ........................ Foundation ------...- ............. Property Line ........................ <br /> SEEPAGE PIT [ ) Depth --------------_.-. Diameter ..-..-----_--- Number ............................ Rock filled Yes ❑ No (] <br /> Water Table Depth ................................................Rock Size ................ ............... <br /> Distance to nearest: Well ........Foundation Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit+# ---... .�R- - . . - . <br /> _- .... Date ................•-•-----.......... <br /> ) <br /> Septic Tank (Specify Requirements[ ........./...... ' ! !.%.. --------------------------------------.--•-•-----_--_-------._-•-...... <br /> .. <br /> Disposal Field (Specify Requirements) ...........--•....................................................................._.. ............................................... <br /> --------•-- -----------------•-•-•................................................................................................................................•--.........I........................ <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 accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.VIstdct. 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 /> ` ---------------------------• ---------- <br /> BY 7itie _. <br /> (if ofher tha owner) <br /> FOR DEPARTMENT USE ON <br /> APPLICATION ACCEPTED BY :T DATE .-. .__ ._... _._7- <br /> ------- ------- <br /> BUILDING PERMIT ISSUED -------------•---- DATE . . <br /> •----------- <br /> ADD <br /> ETIONAL COMMENTS _... - .:.... -----------•--------• --------------------- ---_---------------- --------------------------------I....­_... <br /> -----------------• ------------ -------------------- ... ------......................•.....................................-... ,.. ------------------------ <br /> ­­---------------------------------------- ......­...... <br /> Final inspection by- ------------------ -- --- Date ........ <br /> ...---•------------------------------------ <br /> EH <br /> 3 2!t 1-613 i3v. 5mS 10AQUIN LOCAL HEALTH DISTRICT 3M <br />