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FOR OFFICE USE: APPLICATION FOR SAWATION PEWfT <br /> Permit No. .................... <br /> ....................................+K �� (Contplet.in Tripiicatet <br /> . •. Date Issued <br /> .. ..................................... <br /> TWO Forma Cxptros! Ymr From Dalt 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 mode in compliance ith County Ordinance No. 549 and existing Rules and Regulations: <br /> ....CENSUS TRACT <br /> JOB ADDRESSAOCATI /..`�.��`.�..y�................. .... ............ .�....__..........__.... <br /> Owner's Name / --- ........ �I...�..,,..................Phone -----..................,.-.-------- <br /> Address -----... -/ '.7..5....X. •--••- .. _...City .G, ....................... .......-------- <br /> Contractor's <br /> -- __.Contractor's Name---- L"L`'!_:. ---License Phone . <br /> installation will serve: Residence( i►prtmertt Housefl Commercial[]Traller Court Q <br /> -� Number of bedrooms _-,2_:.Garbage -•-ri•..__.... Lot Size . ..._?��'--- <br /> Number of living units:__. ___. Grinder _/� <br /> Water Supply: Public System and name . --•........................_........_._....-...----...........................................-.`lPrivats <br /> Character of soil to a depth of 3 feet: Sand❑ Silt Q CIaY ❑ Peat Q Sandy Loam Clay Loam.Q <br /> }Hardpan❑- Adobe 0 Fill Materia! ............If yes,type........................ <br /> : \� <br /> (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on rw." side.) <br /> NEW iNSTALLATIONs (No septic tank or seepage pit permitted if public sewer is available within 240 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK ] Size........... ........ Liquid Depth ................ M <br /> Capacity -----......_.- ° • Type ...............--.. Material..................... No. Compartments ......----M � .Q <br /> Distance to nearest: Well ....................................Foundation...................... Prop. Line_........._�..� ..� <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line............................ Total Length .---------------...__----. b <br /> 'D' Box ........_— Type Filter Materia! Depth Filter Material ......................_..................... <br /> Distance to nearest: Well ........................ Foundation ........................ Property line ........................ Z <br /> SEEPAGE PIT [ ) Depth .......... ...... Diameter ................ Number ............................ Rock Filled Yes Q No ' <br /> WaterTable Depth ..............._................................Rock Size ................................ <br /> Distance to nearest: Well ...........Foundation .................... Prop. Line ...................... C <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ............................._.............. Date ........-...•.................... <br /> l 6� <br /> Septic Tank (Specify Requirements) ................................. --... ............................................................. ................................ <br /> D' osal Field (Specify Requirements) ... ............................... <br /> -+'ter. ....... ................... .... <br /> !�� <br /> ---••---•------------------------------- .................................................._ .... .... ............ <br /> i (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. Menne owner or Matti- , <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is Issued, i shall wN ewnpley any person In such manner <br /> as to become subject to Workman's Compensation taws of California." <br /> Signed ..............................•.......---.-.... .. ....... ....... Owner <br /> a-• I �j2... Title !!ca4!.... .-...... <br /> By .....................................••--••--•-_. � Js.c.o.�.. !... - ..._ ............................................ <br /> (lf,other than owner) <br /> FOR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY -. .- • - .:... ..........---------.........:..,..... ,._..,..:.,..,.......... DATE .,..............15........................... <br /> : <br /> BUILDINGPERMIT ISSUED ............................... ...................._.....................................................DATE ........................................... <br /> ADDITIONALa)MMENTS .......................... --.............................................................................................:........................... <br /> ... <br /> .-•..................---•-•-----------•-•--•-----....... . .._............................ <br /> .---........ <br /> -.................... <br /> .-...................................... <br /> ._•---•-.---•---------•-••------- <br /> ----.--.-.---------.- -........ <br /> ............... ... ..-...:--...... ....._.... ...._..._Dote •. 1_....: 1_'7 ... .._-�... <br /> Final lnspectianby: ..----fez- -..__. .... ............................................. .... •- <br /> Eli 13 2h 1-68 Rev. 5tI SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7II 3M <br />