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FOR OFFICE USE - FOR OFFICE USE: <br /> APPLICATION MOSANIATATION'PERMIT <br /> ---- - - 7?�7 � <br /> (Complete in Triplicate) Permit No._____ <br /> Date Issued__l�, ._7'7_ <br /> ..... _ --------------------------------- This Permit Expires 1 Year Fronf Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a¢ermit'to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No.,549'd4d existing Rules and Regulations: <br /> JOB ADDRESS/LOC TION__140 7e _.,,tt��_ r �Q <br /> (�C�/��-1 --•--� ( --------------------------- -- CENSUS.TRACT ,mow - ----- ----------- <br /> Owner's Name---- <br /> —"`'�� C -------- Phone ---- --- <br /> Address Ss Cid ` Gz Zip- <br /> 's Name-. __.-_- _____. <br /> .` .. License #__ '_ I_�_Phone__ -------- <br /> Contractor ° <br /> Installation will serve: Resi ence [ Apartment House ❑ Commercial ❑ Trailer Court F-1tel ❑ Other-------- <br /> Number of living units:.- -----Number of bedrooms____ Garbage Grinder------------Lot Size_ }` <br /> Water Supply: Public System and name--__________ _ _____ ________ _____._ _______________Private <br /> Character of soil to a depth of 3 feet: . Sand..' Silt Q Clay El Peat E] Sandy_Loam ❑ Clay Loam E]Hardpan ❑ Adob [} Fill Material--A,_,-.-.If._.If yes,,type ____-_ . __ ___ <br /> NA <br /> (Plot plan, showing-size of lot, location of system in relation to wells, buildings, a#c:dust be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer,i5-available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTICTAN�K- j -- ze - -. 4. -_ _______liquid Dept. - _ ______JCapacity_ e___ _,:�._ _I-_citterial -__No. Compartments ------------------------- <br /> At, <br /> ___ __--- <br /> Distance to nearest: Well---- <br /> ----------------------------Foundation-. � Prop. Line___ _________ ________. <br /> LEACHING LINE [ ] No. of Lines.----. -------------Length of each line_._-- Total Length..__ _'1-� <br /> .. c <br /> _T a Filter Material- _� `�,.._:De•pth Filter Material l_7._ -_--_ <br /> 'D' Box_ -_Type --- �� ---------- - ----- <br /> Distance to nearest: Wel I--- Foundation____.-----------------------Property Line----------------------------------- <br /> SEEPAGE <br /> ---_ -. _ --SEEPAGE PIT [ ] Depth__ _ __________Diameter.___ ___:Number-__-_ _-__ ____-____ -__ "Rock Filled Yes ❑ No <br /> WaterTable Depth----------------------------------------- --------------- Rock Size.----------------------------------------------- <br /> Distance <br /> ------- -- ---------- - ------------- <br /> Distance to nearest: Well __ Foundation Prop, Line___---------------- _________. <br /> REPAIR/ADDITION (Prev. Sanitation Permit.#.... --------------------------- . --___._Date ________ '_____) <br /> Septic Tank (Specify Requirements).-- - - -- , ,:.. •- <br /> ----- t <br /> r€; <br /> Disposal Field'(Specify Requirements)._-----.--_: _. ----------------------- -_ � �� <br /> - - <br /> ------ ------------------- <br /> --------------- <br /> -------------------------------------------- ------' ------ :'---- - --------------------------------------------------------------- . 4-------------------- - ---- ----------- <br /> (Draw existing and->requirea-additiori'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 County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall'not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed - If -- - -- Owner- - - - <br /> BY / / -- /'l -- ---- Title <br /> --- -------- <br /> h-- ----ei ( fother aownr <br /> R EPARTMENT)4$E ONLY <br /> ------------ <br /> APPLICATION ACCEPTED BY. _____:..______ - ---- ------------- -------------- -- <br /> _ _ <br /> _..._ __DATE:_ "'__ .- <br /> DIVISIONOF LAND NUMBER.-___----- ---------------------------------------------- ----------------------------DATE............ ........ <br /> ADDITIONAL COMMENTS------------------- ----------- <br /> --------------------------- ---------- ---------------- ---------------------- ------------------------ --------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------- <br /> ------ --- ---------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------ ------------------------------------------------------------------------------------------------------------ <br /> - --; - <br /> -- -- <br /> Final Inspection by:. Wil/ --------------------------------------Date.--�,-� 7-7­------------------ <br /> EH <br /> -- ---- ----EH 13 24 SAN AQUIN LOCAL HEALTH DISTRICT F&s 21677 REV,7176 3M <br />