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FOR OFFICE USE: ��` FOR OFFICE USE: <br /> ---------------------------------------------- ------- <br /> X APPLICATION FOR S� .�'TATION PERMIT <br /> - -- <br /> (Complete in Triplicate) Permit No._-/_?-_5�_6 <br /> --------------------------------------------------------- /-�2/- 7) <br /> Date Issued--- <br /> --------------------- --------------------------------- <br /> ssued_.-______________________..-____________.________---___- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to.construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION <br /> ----------- ---------CENSUS TRACT------------------------------- <br /> �> <br /> Owner's Name__Jb-iq---QLD- - �-`----/a - Phone_' 7 _-E)!_(.- -- <br /> Address------ -- -- --------------- -- -----------------City - -------------------ZiP----------------------------- <br /> Contractor's Name____,,_ c._ __ -_____.__•__License #_-��-----Phone__i ��z_: � ____. <br /> Installation will serve: Residence Er Apartment House ❑ Commercial ❑ Trailer Court [] <br /> Motel ❑ <br /> Number of living units:----------------Number of bedrooms____-._____Garbage Grinder_-__._..-_Lot Size__j� �' -7 <br /> n �7, <br /> Water Supply: Public System and name------------------ __ 0% kk (,���c1 s0 u-L-��__._.___-________Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 91 <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 on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> / rr <br /> PACKAGE TREATMENT [ ] SEPTIC TANK qq���,QQQ__ Sizesa,__._K_ ---------------------------------------Liquid Depth__-�'�______.....__ <br /> Capacity.[' --9___Type---- -Material- . ----- ------- ------No. Compartments---- ----.-.-------....-� <br /> i r O <br /> Distance to nearrest: Well---.�`�k---- r-__________________Foundation__-�_ ___________._-Prop. Line_ __.______..___. <br /> LEACHING LINE No. of Lines____!----------------------- r <br /> Length of each line -- -- - - Total Length. - <br /> tr <br /> 'D' Box_________Type Filter Materia9 <br /> l '---Depth Filter Material___�_6--__---_--------_______________--__._.____---_ , <br /> r <br /> Distance to nearest: Well--- 0-*--- ----____ oundation----!__C� ____________Property Line_______' _------------------- <br /> SEEPAGE <br /> __ _-SEEPAGE PIT [a[, De _;�___ /Diameter--JR-O_Aumber------I-------------------_---- Rock Filled YesZ No EDF_ <br /> Water Table Depth------.... 7-------------------- ------Rock Size-1-e7-- to-------------------- <br /> Distance • +s <br /> Distance to nearest: Well----R__k-�'�__-_..._.__._. Foundation_______._______.__.____..Prop. Line-------.______.__________. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__-_____________________..._______._--__---_--Date.__._-_-____________-______.__-.-__-_____) <br /> SepticTank (Specify Requirements)--------------------- -------------------------------------------------- -------- ---------- -------------------------------- ---- <br /> DisposalField(Specify Requirements)--------------- ---- ----------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> (Draw <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 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, 1 shall not employ any person in such manner as <br /> to become suble to Workman's Compensation :17 of California." <br /> Signed.-�P-------1- '` <br /> Vis----� - ( rner <br /> -------------------- <br /> By------ -------------- - - - = TFpdilos <br /> l <br /> If other than owner) <br /> DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_________ _- _ ___.______:__ _____ ? �� -- <br /> ---- - -----------------------------------------------------------DATE _--- -- -------- ---------------- -- <br /> DIVISIONOF LAND NUMBER.----- ---------------- - ------ --- -- ------------------ - -------------------DATE ---------------- ------------------- ---------- <br /> ADDITIONAL COMMENTS-____ ---- __. .__ <br /> ------------------------------------------ ------------------------------------ -- ---- ------ - -------------------------------------------------- ---------------------------- <br /> Final Inspection by:------------ ---------------- - -- -, 's, -_------------ Date--ll"L �Cf"�.. <br /> - ------------------- <br /> EH 13 24 S JOAQUIN LOCA EA DISTRICT F&5 21677 REV. 7/76 3M <br />