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/90 <br /> (IV <br /> FOR OFFICE USE. FOR OFFICE USE: <br /> -' APPLICATION FOR-UNITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> --------------------------------- --------------------- a lV-0�s� s���(Y7l. YL�`t ( q 2.�, -,]-o- <br /> 4 ` Date Issued___ . _7 <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 /> C,t. <br /> JOB ADDRESS/LOCATION---- Y.yJL,------ STRACT------------------------------ <br /> Owner's Name- C ~ J-�-- ------------------------- -------------------------- ---------------------Phone------------------------------------- <br /> Address------------ <br /> --------------------------Address------------ dCoe, HA 5S0 --------- - CitY Tr�1c`y----------------------- - <br /> Zip <br /> Contractor's Name------ '!_.19 7% ----------------------------License #_ 66�Sf --------Phone---5'T--3 '��/� <br /> Installation will serve: Residences[a Apartment House.❑ Commercial ❑ Trailer Court❑ \ <br /> Motel F-1 Other----------------------------------- - C <br /> Number of living units:-------/-------Number of bedrooms---_1--_-Garbage Grinder------------Lot Size--------------------------- i <br /> Water Supply: Public System and name____________________ _ 3, /3• -------------------------------------------------- -----------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam 29 <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-----------------------------------------------------------Liquid Depth-------------- ----------d <br /> Capacity-1_210e5-------TYPe--_'7_r° Material ----------No. Compartments---------:4------------------------ <br /> Distance to nearest: Well-------------------------------------------Foundation_._____�-0_________-___Prop. Line_________________ . <br /> LE11bLG.6FPJE [ ] No. of Lines._�_�_�X__�C' ___.Length - - -of each line________ _________ _ _ __-_-_.Total Length_ <br /> ---------------------- <br /> F1'L Teg, 0rlv 'D' Box-----/-----Type Filter Material----.9®dA------Depth Filter Material----'2a---------------------------------------------------- <br /> Distance to nearest: Well________-___-_________-_Foundation___- ��-___-_-_____Property Line_____'' --______________________. <br /> SEEPAGE PIT [ ] Depth----------------Diameter_--------.--------Number__------------------------------ Rock Filled Yes ❑ No❑ <br /> Water Table Depth---------------------------------------------------------Rock Size--------------- ------------------ <br /> Distance to nearest: Well.-------------------------------------------Foundation--------------------------Prop. Line___________.--__-___-_-_. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#________________________________-___-__.-____- Date----------------------------------------------) <br /> SepticTank (Specify Requirements)------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> Disposal Field (Specify Requirements)_------------ ------ ------------------------------------------------------------------------------------------------------------------------------ <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 /> Signed T-lf G �'--- ------------------------ -------Owner <br /> By--------- -----------------------------------Title---- ------------------ ------------------------------ <br /> o r than owner) <br /> FOR DEP ENT-USE RNLY <br /> APPLICATION ACCEPTED BY_____ '���� ________ <br /> - - ----------------------- -- - --- --- -------- DATE.----- ------ ---------- � --- <br /> DIVISION OF LAND NUMBER-------- - --- ---------------------------------- ----------------------------------------------DATE------------------------------------------------ <br /> ADDITIONALCOMMENTS---------------------------------------------- -------------------------------------------------------------------------------------------------------------------. <br /> ---------- <br /> --------------------------------------- -- ------------ ------------- - - ------------------------------ ---- <br /> Inspection by: - .-_ - ------- <br /> Final Date <br /> -- -----�� -------------------------------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 2ie�� eev. ���6 3M <br /> EH <br />