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FOR OFFICE USE: APPLICATION FOR SAWATION PERMIT <br /> .� Permit No. <br /> -------------------------- <br /> � (Complete in Triplicate) <br /> --------------------- <br /> ___ ._ Date Issued <br /> -74 This Permit Expires 1 Year From Date issued <br /> - � -------- ------------------- / <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 made in/compliance with County Ordinance No. 549 and a mling Pi es cid Regulations: <br /> -'Le'e <br /> JOB ADDRESS/LOCATION - -,5'--- r/� j r���" �'�-eI.W-wW-0. C�NSUS TRACT --------------- ---------- <br /> Phone --------------------------- -------- <br /> Owner's Name <br /> ( � -- -------------------------------------------- <br /> ------------------------------------. City !jrfC _ <br /> --- <br /> Address e� `, <br /> ---------------------- <br /> Contractor's Namef �---------------- License PhonefiL`'�� <br /> Installation will serve: Residence Apartment House'❑ Commercial []Trailer Court :0 <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:___ ---- Number of bedrooms _�d _._.Garbage GrinderPrivate <br /> + --- Lot Size ___ �111vw�- ------------- - <br /> Water Supply: Public System and name ----------------- -- ------------------------------------------------------------ <br /> - ---------------•----•---- <br /> Character of soil to a depth of 3 feet: Sand'D Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom <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 /> p seepage pit permitted if public i available within 200 feet,} � <br /> NEW INSTALLATION (No septic tank or 11 � <br /> S'ze_ 1 ------------------ --- Liquid Depth _ V' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK � - <br /> Type Material_ �r/1 --"---- "No.�Compartments --- ---�-=---- <br /> CapacitylA��--- YP <br /> - -----------Foundation _ Pro Line -- _--� <br /> Distance to nearest: Well -------��-- p' <br /> i ----- ----- <br /> LEACHING LINE { No. of Lines - a -- Total Length � - ------------- , <br /> --------�--___-___ Length of a ch line---- _: _-_ 9 <br /> .De Depth Filter Material-_,,��--------------------------------- <br /> D' Box � __ Type Filter Material /��; P � <br /> Distance to nearest: Well __- �_-_---- ___-- Foundation __ -- <br /> ------------ Property Line -- --•-----.-.... <br /> ` ` _ Rock Filled YesA' No i❑ <br /> dr <br /> Diameter --- Number ----__ --------- <br /> SEEPAGE PITT Depth -- -- ---- a is <br /> i <br /> Water Table Dept — <br /> -----Rock Size ----------------- <br /> h ---------f -- <br /> ,IIFound _-�� <br /> ation �------. Prop. Line _t -___........ <br /> Distance to nearest: Well -____ � �------------------­- <br /> REPAIR/ADDITION(Prev. Sanitgtion.Permit# -------------------------------- - <br /> -------- Date ---------;----------------•-------j -, <br /> ----------I-------- <br /> Septic Tank (Specify Requirements) ------------------.-------------------------------------------- ------ ----_---'=---•----------• ---------- <br /> Disposal Field (Specify Requirements) --------------------- <br /> ` _ - -------------------------------------- <br /> ------------------------------- ------------- <br /> ------- <br /> -- --------------------------- <br /> ------------------------------------------------ -----•-------- 7-- -=----- <br /> ------ -------- ------ <br /> --------------------------------------------------- ------------------------------------------------------------------------------ <br /> ----------------------- - <br /> I (Draw existing and required addition on reverse si d e <br /> I hereby certify that 1 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. Home owner or licen- <br /> sed agents signature certifies the following: <br /> '� rwhich this permit is issued, t shall not employ any person in such manner <br /> I certify that in the performance of the work fo <br /> ds to become subject to Workman's Compensation laws of California." <br /> Signed = - Owner <br /> - ------- ---------------- <br /> �- ------ ---------- - Title <br /> F - - - - - �� ------------ --------- --- <br /> By --{lf-- er han owner) <br /> f 'FOR DEPARTMENT USE ONLY <br /> ------ DATE --. -1� -�'' -------------------- <br /> APPLICATION ACCEPTED BY ---- --- -- --- - -- --=---------------------------------- <br /> BUILDING PERMIT ISSUED ---. -- <br /> .= -----------DATE -------------•----------------------------- <br /> ------------------------ <br /> ADDITIONAL,COMMENTS ------ ------------- ------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------- <br /> i --- -- ----------------------------------------------------------------- <br /> - <br /> - - ----- <br /> Final inspection by: Date <br /> � SAN JOAQU1Iv LOCAL HEALTH DISTRICT <br /> z u o 1_1AQ Pn riM <br />