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FOUR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. �.._ X70 <br /> (Complete In Triplicate) ,._.7.. .._..-----•; <br /> ..........I.......................... ......... <br /> .................................................. This Permit Expires ! Year From Date lamed <br /> Date Issued .//.............. <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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .............-_-..s. -ia------- ........ -----_- ...___-CENSUS TRACT .......................... <br /> 1�2Owner's Name •----- 1...... � <l�? -----•------------- .., - ...._........._....................Phone ------------------------------------ <br /> Address %-* <br /> Contractor's Name ---- ._ __.License# % _. Phone _�1_/._�_ <br /> - -----------Installation will serve: Residence partment House❑ Commercial❑Traller Court fl <br /> Motel ❑Other----- ------------------------------------ <br /> Number of living units:-....r... Number of b s _____Gaarbb a Grin e��.._. Lot Si _/i l�U � .............. <br /> �/" . <br /> Water Supply: Public System and name . ...... . ... _....__ ... .......... ..........-- -._.Prfvate❑. <br /> Character of sail to a depth of 3 feet: Sand❑ Silt❑ Clay Peat© Sandy Loam 0 Clay Loam 0 <br /> Hardpan❑ AdobeFIN Material _.,l �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 204 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f } Size—_....................... .................. Liquid Depth ........................... <br /> Capacity . Material.................... No. Compartments <br /> Distance to nearest: Well ....................................Foundation ---__.__..... ........ Prop. Line ...................... <br /> LEACHING LINE [ } No. of Lines •-------------- Length of each line............................ Total Length .......................za- <br /> 'D' Box ......_ ---- Type .Filter Material ....................Depth Filter Material ........................................... <br /> Distance to nearest: Well ________________________ Foundation ........_............... Property Line ........................ <br /> SEEPAGE PIT [ j Depth -------------------- Diameter -___-_______---- Number ........•................... stock Filled Yes ❑ No <br /> Water Table Depth ---------- ------_-----.......................Rock Size ...................... ......... <br /> Distance to nearest: Well -----------------------------------.....Foundation ..................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prey. Sanitation Permit* ----___-....... ............ Dat ....................... <br /> Septic Tank (Specify i2equirementsj ...... 4 ._ __-- 1�..oi.'.--.- �� ...�/fd .0 <br /> Disposal Field IS fy Requirements! .... -27_! � � ��° < _. __. <br /> -• •------------------ - I-------------------------- ----------------••-------------........................ <br /> (Draw existing and required addition on reverse side) <br /> 1 hreby 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. Horne owner or licew <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -----•- -- -- Owner <br /> By ........ other <br /> then <br /> owned ••••----------------------- Title . /,1.�7�......_....--------- <br /> 1 other than owner) <br /> FO& DR4RTMENUSE ONLY " <br /> APPLICATION ACCEPTED BY _._-- ---..---.-_.-•---- __,_ DATE _1 ..�. ....- .,Z�' — <br /> BUILDING PERMIT ISSUED __. •----• ------------ <br /> --- ---- -- DATE <br /> ..........ADDITIONAL COMMENTS ............................... ...__........ - -..._..._.... <br /> ------------------------ --------------------••---------------•--•---------------- ........ ------------­------- ------------------------------------------ ........................ <br /> ------•---------------••--------•- -- -- .- -- --- <br /> Final Inspection by: -• ..............•---• --------............--...._....-------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />