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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> ............... This Permit Expires T Year From Date Issued Date Issued <br /> Application is hereby made to the San Jooquin Local Health District for a permit to construct and install the work herein <br /> described. This applicatien.is.mode in compliance with Count Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LUC— ION .... D���- ! ca �S?- 3 00—/0 <br /> ( t ._._�.... .....CENSUS TRA ................... ........ <br /> Owner's Name © t9 <br /> ... ---- v _ .l._ -�- ---------- <br /> ---------- ----------- Phone .. -�r� <br /> Address �� 1 _...1. � .- City --- `-n,/ ...... ---- <br /> Contractar's Name .. ._.... ....-�_E9. C � License Phone 9..-�.r' ..:1 <br /> Installation will serve: Residence Vpartment House❑ Commercial ❑Trailer Court C1M <br /> ote ❑ Other .. ._j. .------. -• ----------------• <br /> Number of living units:,... Number of bedrooms .1.....-----Garbage Grinder ..._....... Lot Size <br /> ....... --�...... <br /> Water Supply: Public System and name.......................... Private X }� <br /> Character of soil to a depth of 3 feet: Sand Silt [) Clay [] Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan lk Adobe ❑ Fill Material If yes,t <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: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) I <br /> PACKAGE TREATMENT I } SEPTIC TANK[ ] Size...... --- -©.---.-- Liquid Depth .. _._._... <br /> Type ©� <br /> Capacity 240-. Materiaf.�B --.-.. o. Compartments ��- <br /> Distance to nearest: Well ' k <br /> ..............._....___._...Foundation ..... Prop. line ..._�__.. ---------. <br /> LEACHING LINE [ ] No. of Lines ... !._. Length of each line ........411,0.._ ...... Total Length .....�Q.._. <br /> lell1 I! c� r r to <br /> D' Box . _ Type Filter Material 1/2 <br /> ------------ Filter Material ....�...,I--.................... (b <br /> Distance to nearest: Well _.:..`._- --0---_-- - Foundation ...a©..----...... Property Line ........................ <br /> G [ J Depth j7 .--.--...—Diameter _ Number <br /> SEEPAGE PIT / - ? � ------I...... Rock Filled Yes No [� <br /> Water Table Depth ....... <br /> +.............•---------------------- Rock Size ---�..--_2-, <br /> !----------- <br /> Distance to nearest: Well .....�.©©----------- -----------Foundation _41,_ ....... Prop. Line .................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......... .......... .......-..------------ Date _---.-.-..-..-__------- <br /> ptic Tank (Specify Requirements} ........... -- .................. ------------ .......... •---- <br /> b <br /> Disposal Field (Specify Requirements) --------------------------------- ------------------.------_-- •- <br /> = F <br /> ------------- ---------- ............ ---------­­------ ! <br /> -- ---- •---- - -------.._--------- - ------ ----- --:.*- :. <br /> (Draw existing and required addition on reverse side) ' <br /> 1 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 /> "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 ubi ct t W man's Compensation f California." <br /> Signed .:.. . ---- Owner <br /> By <br /> --------------- Title . !�................. . . --- <br /> f ther than owner} , <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ... . <br /> ACCEPTED BY <br /> BUILDING PERMIT ISSUED ........................ .. .. .. ��� ........ DATE -.. � 2 <br /> ••......................... <br /> .-"- -. - " - - . ...._.DATE . ...........I--------- ------- <br /> ADDITIONAL COMMENTS ................................... <br /> ------• --------------- ­­-------------------------- _............._..............................---- • ..............---.. ..---•-------- .................- --- <br /> ............. ................ ....... ........ .. <br /> Final Inspection by ..-- <br /> : .. - .._...:.. ..... ----•- -- -•................Date ..j�l .. .... ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> C W 13 24 , to n_-. C.. _ •-- _ <br />