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` ". '. .._ <br /> ' 'FO'.YOFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR"SAP.%&TATION PERMIT <br /> ---------------------------- -- ----------------- : <br /> (Complete in Triplicate) Permit No. -------- <br /> :Date Issued------ <br /> ---------------------_---------------------------____.._= 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/LOCATED ---I L_fo ___ .t-, !_; ..- --j-. ---- - <br /> - ----------------CENSUS TRACT- <br /> ------------------- <br /> Owner's Name_" -------------- ----------- -------- -------Phone`f/ � .7��. <br /> Address �� / lam.:_ ----- City rR Zipd/ <br /> p r <br /> Contractor's Name_.°_________ ____'____. _ <br /> . -It...... _ - -_License # ��'_3 .. ----- <br /> � _ Phone---- ---- <br /> Installation will:serve: Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court <br /> ;.� . 4. Motel F Other------ <br /> I _. <br /> ------------------------ <br /> 4 <br /> Number of living units:_..----- .___Number of-bedrooms--- Garbage Grincler------------Lot Size---------------_.............. <br /> Water Su I Public System and'name------------------------ - --- - - --- -----------_ - -------------------_ _Private <br /> Character of soil to a depth of 3 feet: ; Sand Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam' <br /> r Hardpan ❑ Adobe;K _ Fill Material--------------If yes, type----------=-----------------_--_- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must beplaced on reverse side.) <br /> NEW INSTALLATION:' JNo septic!tank"or seepage' it permitted if public sewer is available within 200 feet,) <br /> r PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size___________________ - --_-__Liquid Depth - ------ <br /> ( ) �- Capacity---I-' ------'--__ ._TYPe._____:--___-------___--Material--------------------- -- _No. Compartments ments.______-_-.- <br /> ------------------ <br /> ( I <br /> . .Distance'.to nearest: Well-,------'-------------'.---------------------Foundat.ion--------- -------.------._Prop. Line----------,------------- <br /> LEACHING LINE: [ ] No. of Lines--__.______:.-----+---------------Len-g'th, of.each line-------------------:-------------Total Length------------------------------.- -_--- ti <br /> 6 <br /> Type <br /> ------------------------------- <br /> Distance <br /> -- - ------------- ---- <br /> .... ... -�----------------Depth Filter Material- --------------=------- - -- - <br /> Distance to nearest: Well------------- -- ---? . - ., » <br /> Q' Box._____..___7 a Filter Materia _. <br /> - ------'------Foundation----------------------------Property Line.----------------- ----- -- <br /> SEEPAGE PIT [ ] Depth.----------------D.iameter_;__---__.-----'--_.Number---_----------------------------- Rock Filled Yes❑ No ❑ ' <br /> Water Table Depth ;- --------:-- - --- --- --- Rock Size----------------------------r------------------- <br /> F Distance`:to nearest: Well--._'----`------------------`-------------Foundation-----------------___--._.Prop. Line---------------------- <br /> ----- <br /> 4 REPAIR/ADDITION (Prev. Sanitation Permit#__.-__.-'_::._ ------- _;.___':Date_..----- ] <br /> Septic Tank (Specify Requirements) = --=---------- ===` <br /> f r <br /> Disposal Field (Specify Requirements) _ �-. K ''_ 2Zf ------- ------ ---------- --------- - <br /> } <br /> l �`1S- ------------------------------- <br /> ------------------------------------- _ _ <br /> ----------- ---- - --------------------------------------- - --- <br /> r a - (Draw existing and required addition on reverse side) s rt <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count}► <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed agenta <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 /> I � - <br /> Signed----- ... ........ - -- Owner <br /> $Y -------------- ------- --------- - -- ---- '� Title - --------- <br /> ----- i <br /> (If other than_own er <br /> FOR DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTEDBY -- - --------DATE.---6..-'_-^-�-,7 . ------ <br /> DIVISION OF LAND NUMBER--------------------------- DATE.-. = <br /> - <br /> ADDITIONALCOMMENTS----- ----------- -----------------------------------------------------------` -- --------------------------------------- .--'-------'--------------------------------- <br /> -- - ---------- ----------------------------------------------------------- ----------------------- <br /> Final <br /> - <br /> Final•Inspection by:_A--- ----=----- -- - - - " - '' „'..._ - Dater '- j- "� . .J - - + <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT -F&S 21677 REV, 7/76 3M <br /> 4 <br />