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FOR OFFICE USE: -� � FOR OFFICE USE: <br /> APPLICATION FOR SA? TAT10N PER7yAJ76-' <br /> -- 1FS-S! <br /> (Com*, in_Triplicate) Permit No... . . � ....... <br /> z= <br /> • Date Issued 45 <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/LOCATION _Y ­0­17-_ _..__. <br /> -��'�� _...- _-.�.r :'+��� -- - - -. ---...�1.�-�� ..CENSUS TRACT--...-..-. -..... <br /> Owner's Name __040-371.- - / LY`1 7 `' -....a`f:4.tWr-Y-x/t_.. _..S_('-11t5_,7_7'-'1__ <br /> _ • ....._.Phone ._- ---- --•--- • - <br /> Address. C S-�.lam J- ----- - ---- ---- - - -City----- � <br /> Contractor's Name__ _�T./'} t_.�-E.. �1r�..�� 4-f .nJ. !.C:61-�,- license #-3.j:�j'-I- Phone r( ( Cl .r <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court <br /> Motel ❑ Other__CFjL=rCJF.------------------- <br /> Number of living units: ---------Number of bedrooms-.'1 Garbage Grinder_..........Lot Size.__..--.J.�_ <br /> Water Supple: Public System and name.- - --------- -- ------- ------ . _._ _ . --------------- ---- __-------------- -- ....... -- __ ----- ------...Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay Peat ❑ Sandy Loam ❑ Clay Loam <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 /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size - <br /> _ �X-•S ]'S--�---- ---n-��- - - - Liquid Depth.--, _--2........ - ---� <br /> Capacity_z�{eC !t�Type. � -t- W�.i.Material_C Compartments.----- ... . <br /> Distance to nearest: Well-------- c .' ------_... .........Foundation__ I a-`____ . Prop. Line .'. . .. . .. ... <br /> LEACHING LINE [PQ No. of Lines <br /> _,.�..._--_...._.Length of each lineTotal Length .-.-- ........... <br /> Box CQ -.Type Filter Material Depth Filter Material__.-- ..--- -`1.:'_. .--..--.---- ---------------------. <br /> Distance to nearest: Well-----1-0-0` .... Foundation.___.__1� .-_.._.-.Property Line___.._-LS��_.-___ ....... <br /> SEEPAGE PIT [�j Depth- :5.'. _Diameter. . _44 _- Number � __--- . -- Rock Filled Yes^ No <br /> ENt <br /> Water Table Depth.-- -- ---1 C'&_. .... ---.-------------Rock Size_- -------:2'1 -------- ------ <br /> Distance to nearest: Well .-----)Qtr -- ---- -- ------Foundation__.-_C C'.�_.'__ Prop. Line ._. ._ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#..-.--------------.--- ------- - _-----------Date_..........------ <br /> Septic Tank (Specify Requirements). _ ---------- <br /> Disposal <br /> - ---Disposal Field (Specify Requirements)_..- -- ------ ------ - - - ------------------ ........... ---- - -- ----- - <br /> ----- ----- ------- - ------------------- <br /> _..---------- --- ---- ------- - - - __--------------- --------------- - - -- -----•--- ------ ----- - ---- -- - --------- -------------------­ <br /> ----­--------------_ <br /> ---------------------------------------- --- ----------------- - - -- - -- ----------- -- ------------------- ------ ---------- - -- ---- --------- -----------------------I------- <br /> (Draw <br /> ------------ -------•------- <br /> (Draw existing and required addition 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,ss/ubi to Workman's Compensation laws of California." <br /> Signed_--- 61 (� C. �1 ' -� �C.� vC`:cl. ---- --- ---..._.Owner <br /> By------ -------- ------ --- -- .. Title---- ---------- ........ ---- ------ ----- -- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-. .. .__..___DATE ._-- -" S- --- ------ -- - --'-- .. <br /> - - <br /> DIVISION OF LAND NUMBS -- -.--- DATE.------ _._. .... <br /> ADDITIONAL COMMENTS --- -. --- - --- -- --- - <br /> f,,, - 1 <br /> ------------ <br /> -- _ -- .. <br /> �.�_ <br /> - -- -- -- <br /> . <br /> Final Inspection by: 1i/',_ --- -_ ._Date 6_ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/7e inn <br />