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FOR OFFICE USE, APPLICATION FOR SA14liATION PERMIT <br /> Permit No. <br /> - � - (Complete in 7riplicate) <br /> .------ -----------•----- <br /> Date Issued <br /> ........................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health Distri t for a °permit. to construct andinstall the work herein <br /> described. This application is made in compl]pnce with'Caunty Ord.inanceNo;549 and'exist6g;Rulesland'jRegulotions: <br /> . �51 <br /> JOB ADDRESS/LOCATIO ............. ... . sus TRACT -- �_ <br /> Owner's Name ... ..../.%J SD V.Zai........- '_'::......I.........:....- ......:.....--------.......Phone. <br /> 1.........City �KI......... :C.!9`?... ...:= ' / ..._.... „ <br /> Address -S444-fir '- ......• .....................- P� <br /> Contractor's Name ..----�` ......... '1 f2�f�•Q-----------------1..:........License A.ys.�jpld.-.-. Phone <br /> Installation will serve: Residence ❑Apartment House❑ Commercial❑Trailer Court ❑ 1 <br /> Motel ❑OFher..........._........ ....... ............. �,n <br /> Number of livingunits:... Number of bedrooms ..�...Gar age Grinder ............ Lot Size AQ4!/tewY'e.............••.• <br /> Water Supply: Public System and name ........... _ Private [$' <br /> Character-of.,soil to.o depth of 3 feet: Sand 19 SiltC1 Clay [I PeatR� Sandy Loam C1 Clay Loam ❑ <br /> Hardpan❑ Adobe ❑ Fill Mcterial AVY_.. 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.) W <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) N <br /> PACKAGE TREATMENT [ ] SEPTIC TANK( ] Size... .... .............................. . . Liquid Depth ........ <br /> Capacity ....... Type .- ..'`--....... taria,...--- ......... . No. Compartments .............. <br /> Distance to nearest: Well ............. Iin__I oundatio .........-...........- Prop. Line .........,....;-.._-- <br /> • LEACHING LINE [ ] No. of lines ........................ Length of elIach line._......-- ...... - ---- Total Length ............ <br /> 'D' Box ............ Type Filter Material -....1.............Dept ilter Material ............--------------------••--.--•••- <br /> Distance to nearest: Well ..--.. Foundation --... Property Line ........................ <br /> Depth Rock Filled Yes No 1❑ <br /> SEEPAGE PIT [ 1 P ----��-�-�-----�-��- Diameter . ............ Number - • - - - ❑ <br /> Water Table Depth --------------- .................I�I.......... ock Size ............... <br /> Distance to nearest: Well .... ...... ............1...- -.Fou ation Prop. Line .......-- .......-... <br /> REPAIR/ADDITION(Prev. Sanitation-Permit# ....... .. ...................i.---- --- ate ...............--.........--------) <br /> Septic Tank (Specify Requirements) .............. <br /> -- ...-- <br /> Disposal field (Specify Require ants) .....] •--..... r <br /> - . <br /> _ . . .. - <br /> (Draw existing and required aIdition on reverse side) <br /> I hereby certify that 1 have prepared this application and that he 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, t shall not employ any person in such manner <br /> as to become subject to Work an's Compensation laws of Calif nim" <br /> oe <br /> Signed ... .- --- — . -......------....///....���.-'t----�- --jj-•7�- I_ Owner <br /> -. <br /> r�... :C_...../..............` J. Title <br /> By - ... - <br /> _. <br /> ... .-- - <br /> -- --- --- . .. ----- .._ - <br /> -....... . -- <br /> (if other than owner) <br /> FOR DEPARTMEN USE ONLY <br /> APPLICATION ACCEPTED BY...... `-.... - - -------------------------- DATE:......... ..7/:n.7 <br /> BUILDING PERMIT ISSUED .----- -------- ............................... ......... ..._...........................------...DATE ................... ... -------------- <br /> ADDITIONALCOMMENTS ....... - -'......---- ....._ -.. .................- ----. ......... ............... .. .. ._...._......---------- ....-.... <br /> .... - . <br /> - <br /> .------ _....... t <br /> r _. ............._. ... - <br /> Final Inspection -- ------......Date - - -r 7L .......... <br /> SAN JOAQUIN LOCAL I <br /> HEALTH DISTRICT <br /> 1:/.A Do., SAA <br />