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4 <br /> FOR OFFICE USE: l�APPLICATION FOR SfTAT�ION PERMIT� FOR OFFICE USE: <br /> R� � ' <br /> (Complete in Triplicate) Permit N.o.. ... _ ��.'. <br /> Date Issued--- <br /> .. �'� <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/ G[J6_S T Lk}.t/E ...............CENSUS TRACT............. ----- --'--'---- <br /> Owner's Name L't-_ �./,. -I�UK�,S-L.EuJSKI�_Phone.... ----Z$ <br /> Cont actor's Name.--'-- i? /�l 4s-g ...S0,v.-S-.__..--------- -.... . Z.�lo�--- <br /> Cit <br /> License #o�f�-,3�3 Phone... <br /> Installation will serve: Residence ❑ Apartment House fl 1 Corr merclal'%_Trailer Court❑ <br /> _ <br /> Number of living units-----------------Number of bedrooms--..-.--.. Garbage Grin ar--------- _Lot Size-_-AC,�E�}frE :- <br /> Water Supply: Public System--rind-name..._.0 L• �,+� �.._�..-... . -f/ G�..C. -----------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑. Peat ❑ Sandy Loam C3 Clay Loam ❑ � ] <br /> Har'dpan ❑ Adobe Fill Material.. ... ....If yes, type.•------------------------------ j I <br /> s <br /> (Plot plan, showing size of lot, locafion of system in relation to wells, buildings, etc. must be placed on rever..se side.) "J <br /> NEW INSTALLATION: (No ,septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [0- Size...—.----- -------------------------.-----------------Liquid Depth._..Sy- G <br /> apacity P. ----Type--REGT Mat�rial._.CQ�tJG No. Compartments <br /> Cp ---------Z-_---- <br /> Distance to nearest: Well-:---__.-.. :-:_ ------­^-"""- --_Foundation_...,Q./..-t4........Prop, Line..... -........ ---..-.�- <br /> LEACHING LINE [ No. of Lines ..................Length of each line.-- Tom'...-........... Total Length­;. -- -------- <br /> 8 <br /> .'D' Box._.Ie. ..Type Filter Material....,5./.�._ .....Depth Filter Material-. -----.-1.._.....__.............. <br /> _Di.stance-to nearest: Well----------------------------Foundation----1 ___4'_ .-......Property Line. T.----------- ----- <br /> SEEPAGE PIT Depth. -----T.�_�_.....Number--- ---------/-------------_.___ Rock Filled Yes` No❑. <br /> 3 /J //Water Table Depth.--..._._ -------------------Rock Size..... <br /> 31 /J <br /> X I�._ ---------- ---- <br /> Distance to nearest: Well.............._---...------....--------..-Foundation....... ......Prop. Line.-...,Srf.. --_--_ <br /> REPAIR/ADDITION (Prev, Sanitation Permit#..... ......:. .---..._. Date....._......................-.._.---------.---) <br /> Septic Tank (Specify Requirements)---- - -------------------------------- ------------- -- ---------'---------- --....._------ ...... -......,_.....-- i <br /> Disposal Field (Specify Requirements)-..... ---.--•--..-; . ........... _ --�` -� <br /> -- ------------- <br /> 1 <br /> ------------------ -------------------------------------- ------------ -------------------------------- <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 subject to Workman-'s` Compensation laws of California." <br /> a <br /> Signed--=--' �----' - � ��. . .......... ............. ....' '--••:-------- - ---' ' -Owner <br /> -. . Title.._...._4.SST../.-f a ' ' <br /> (If other than owner) <br /> OR D PARSMENT USE ONLY <br /> APPLICATION ACCEPTEI] BY -. -- -' J` ----- ......... TTE .. . ..' ..DIVISION OF LAND NUMB D . _---.....-------...----....--'- ] <br /> - - - - -- <br /> ADDITIONAL COMMENTS.; <br /> c�,�ytJfo - C /�� ----------------- -'---..:--------------------------------------------- -------------- - -' ... <br /> •------., -- - ' . ................. ---------------------- <br /> Final Inspection by':.`... <br /> . . WilL. <br /> ----- -------------- --- ------------------ Date.- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 2W7:REV:»7/76 3M <br /> 4 <br />