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. � « <br /> -11WFR POFFICEtUSE: <br /> APPLICATISANITATION PERMIT <br /> ` <br /> ` ' � w- ^��'� ( �mn`p|e�e|m �H�M*w�� Permit No, .�Y����n^=°w~x�� <br />. _ _. � �� <br /> Doh, buu _m�*�-��°° <br /> ~ ThisiiOxm ��«�� <br /> Applicationtoth�Son Joaquin Local Health District for aper"mit to construct and install the work he,en <br /> . <br /> described. This application is made |n compliance with County Ordinance No. 549 and existing Rv/uy and Regulations.. <br /> Address ----------------- ------------------------------- city - ------------------------- <br /> Contractor's <br /> --' <br />� Cont,octor'oNomn �x��J��?� ---------------------- -------Lio,nse 21 Phone <br /> Installation will serve: Reai6 Apo,onani House f] Commercial f7Tnoi|enCourt �E] <br /> Motel []Other ------ --------------- ------.-=--I <br />' Nvm6r, of living units: ---' Number of 6n6,00mm ------------Garbage Grinder ---- Lot ^ <br /> Water Supply: Public System and home ..~��u������.�.���-'---.------------Phvoha <br />. ' � �� � <br />' �o�� � �|| �o6o;� �3 �� �nd� �3i|t:[] Clay M Peat Sandy Loam Clay Loam E] \ <br />� <br /> Hardpan EJ Adobe E�J-~F|UMaterial ------------- Ryes, type —.--._---, � <br /> -- <br /> (Pht plan, showing size of lot, |ocohon of syxmon in relation to- wells, 6vi|6ingo' o�. must be p|ocu6 on reverse side.), <br /> NEW k or seepage pit permitted if public sewer is av3ni ble within 200 feetJ <br /> PACKAGE TREATMENT f I SEPTIC TANKf Liquid Depth ---S.4le-1----------------- <br />� 'D' Box ----- Typo Filter Material epth Filter Material .--_-'-_--'_ <br /> Property <br />| SEEPAGE PIT <br /> _---__----' ' . . - . ^� No -~ <br /> ��o ` <br /> Water To6|o Depth -.-..^�-'--.--------'�oc� Sizw <br /> , <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop Umo <br /> (Prev. Sanitation Permit# --------------------------- ---------------- Date ---------------------------------- <br /> i <br /> -_'----'--'_-i <br /> Septic Tank (Specify Requirements) ------------------------------------- ---------------------------------------------------------------------------,---_--_--- <br /> Disposal Field [Specify Requirements) .--_-_--'__-.—.---'--._------.—._--___—'-- <br /> ------ -------------------------------------- ------------------------ ---------------------------------------------------------------------------------- ------ --------------------------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------'—_--'-------- U- � <br /> ^ (Draw existing and required addition onreverse side) v� <br />' | hereby certify that I have prepared this application and that the ~vm,k will be done in mm*or6an*m with Son 2mmqwim <br />| <br /> County Ordinances, Smxwo Laws, and Rules and Regulations of the Son Joaquin Local Health District. Homme w*vnww or [i*em+ <br />.. sed agents signature certifies the following: <br /> '1 certify that in the performance mfthe work for which this permit is issued, U nhm|1 not employ any'�werson in such manner <br /> as to become subject to Workman's Connpensmtiwn'|wws of California." . <br />� S/gne6 _- ----.------.------- Owner <br />' my��6�}�~�}�� ---------------------------- Ti,|e -- --- ------------ ---------------------------------------------------- <br /> (|f cxhthdn owner) <br /> - FOR DEPARTMENT USE ONJY <br /> . �. - �» �- <br />| APPLICATION ACCEPTED ---� DATE -- ---.~_"'~~��-,~°-- <br />, 8U|U]|NG PERMIT ISSUED _---�-- --�--�----.-�--_'��-.--_----.—.--''DATE ------------------------------------------- <br /> ADDITIONAL <br /> ---------__ADD0ONAL COMMENTS -----.---._----.--------------------- --------------_---------.- i <br /> ------------------------------------------------------------ --------'--._--.—.—.—.-------.----'-----------' <br /> ���- --------------------' �_�'����'�_�����'����_ <br /> -------.—��� __-_77777 <br /> ------_--.--�-- .���*^-- <br /> �no| |nopecion6y �7. --'.x��� —'-----_-Date -�����'���'. -,~�---. <br /> SAN JOAQU|N/LOCAL HEALTH DISTRICT <br /> E H 9 1 '68 Rov. 5AA / <br />