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FORC� � ' ' � � ~ r <br /> APPLICATION pOR8AN|TATON PERMIT FOR OFFICE USE. t <br /> (Complete in Triplicate) Permit <br /> Date <br /> -,ThisPermit <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 c1lounty Ordinance No. 549 and ex ules arli26Remulations: <br /> JOB ADDRESS/ 0 ATIO <br /> -rX4 <br /> Owner's No <br /> 40/1 <br /> Contractor's Name. s <br /> Installation will serve: Residence artment House E] Commercial n Trailer Court <br /> Number of living units: ------Number of bedrooms.,3- ... Garbage Grind: ....Lot Size- ---------- <br /> Water Supply: Public System and name..... <br /> S _Clay F m'E] Clay Loom <br /> JPlot plan, showing size of lot, location of system in relation to wells, buildings, etc. must'be placed on reverse side.) <br /> NEW INSTALLATIOW. (No septic tank or seepage pit pc�rmjtted if public sewer is' available within 200 feetJ <br /> LEACH/NG LINE [ ] No.. of Lines-------.:--Length of each |ina.--------.,—Total Length -----'-------.J7 <br /> - . <br /> �' 8ox----Type Filter Material —.............._DepHh Filter Material -- ------------------------------ ........ ............. <br /> �� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joa'quin 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 /> (If other than owner) <br /> APPLICATION ACCEPTED BY- ...............................DATE .........7//rY.7` 17 <br /> —'---------^--------`-----------------------------------------'' -------- --- <br /> ---.--- ___ .— ....... ...... —................ ............ --------- --------------- -------- .. --- — ----- <br /> .--.--.----'---------' —'^_---.--� ---� . <br /> �no| |nxnecno� 6v.................. <br /> ~ ^� Do�e�' ' �/ <br /> .~ ' ---------' —' —"--~—cr ---' . <br /> EH 13 m / SAN ��U|N 0 A HEALTH DISTRICT � m� REV. 7/76 3M <br />