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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE <br /> ' J <br /> Application is 6en,6v made to.the San Joaquin Local Health District for o permit to ' <br /> �~ ~~' ^m,o,t and�iinstall the <br /> ,o <br /> rk herein <br /> described. <br /> ./»o application is mode in compliance with County.O,6inonoa No. 549 and existingRules and -v|ohonv. <br /> JOB ADDRESS/�- CENSUS TRACT----- --- <br /> — '.-- --~' ---- --'—'-- -' <br /> —�—�—`' <br /> Owme,'o Nome—. <br /> Add % ----- , <br /> —b',.m,u <br /> _. -^—_---- city <br /> -------- <br /> Contractor's mone— ... — Lice�ue #-�. ~'*Tz ~—.Pho <br /> nV6 � <br /> Installation will serve; Re <br /> — <br /> Commercial El Trailer Court F1 ' <br /> � | ""°'"' E] Other_ <br /> Number of living unit�--�,_..N ' be, of bedrooms-. �� Qo,bugc G,indem-----.......Lot Size----- <br /> Water <br /> .—VVoter Supply: Public System and name_ ' <br /> � -----'— <br /> `--------------------------------...--'PvivoKe 191 <br /> . <br /> Character of u,i| to o depth of 3 feet Sand Ej Silt Clay E] Peat E] Sandy Loom [j (]oy Loom [:j <br /> � <br /> Hardpan El Adobe Fill Material ---]f yes, type----------' <br /> . i'.v, plan, showing size of lot, location of system in ,a|ohon to wells, buildings, etc. must be placed on reverse side.) ----------' <br /> I NEW INSTALLATION. (Nn "septic.' nk or seepage 'pit permitted ifpublic aevvor isavailable within 2U0h,at') <br /> PACKAGE TREATMENT ( ) SEPTI C�TANK [ ) ' Size........... -- <br /> --------------------------- ----------Liquid Depth �� - ' <br /> Capacity_ ----..Typ*------- �Ao�nioL'_---��`_.No Compartments -,.-.. � <br /> \ — <br /> Distance to nearest: WnU_'— ........ -----—------ ------ .Foundation------- ---- _---Prop` Line------- ---' -- <br /> ~'^r~~~' ' '"`" wp"`"v nequ.nnnenrsc—��.��-.—.` �.�.y�8��.—��L��_'�J0.�. ^��\ ���T. <br /> � ' .--. —�—. ----------------'- <br /> -'—'---.-----'------ ------.----.................. <br /> ------, <br /> � —_—.-------------- --------------------- <br /> ---------------- <br /> ------' <br /> } —'---'—'---- / <br /> � <br /> (Draw ---''=' and required add^'"'' "" reverse side) <br /> � | hereby w*,Hfy that ] have prepared -thiw mppUupGom and that the work will be done in accordance with Son Joaquin County <br /> , snx|mwncey, State Laws, and Rules`' and Regulations of the Son Joaquin Local Nem|N` Oivni,t. Home owner o, licensed mg*nh^ <br /> signature certifies the following: I <br /> . <br /> / *o,Nfy that in the performance of the ""w,k for which this permit is issued, | shall not employ any person in such manner as <br /> to b <br /> Signed <br /> ' ------'---- — <br /> ---''t— ---------------Title----------1�_______________� <br /> (|f other than. d <br /> OOR.DEPARTMEN' T USE ONLY� ArruC*//uN ACCEPTED BY....... ...... ................................... _ -----------'-------------—--------------- —�O�TE-- ----- ' - <br /> CVV10ONOF LAND NUMBER. ------� <br /> ---------------�—�--------------.----DATE--_--- ' <br /> ADDITIONAL CCoWMEMTS—'�—_----��---------------'���-----------------' ' '�----- <br /> . . .� -----------'' <br /> —'----------- ------ ............... <br /> --''�------------------'---_--------'__---' � <br /> ' --------� <br /> ---------................. —......... . ..................._ ....._ .............. ........... ----------------------------------- ----------------- ^ <br /> —.---'—_-----------'"---'--_--^.~°-------- - --------� <br /> -- <br /> Final 6v ', ----------------'—'--------- ---- <br /> ,"" _'�_______________--________ _ ___—.--------Date----------------� <br /> � m � <br /> SAN JO�QU|N LOCAL HEALTH D�TR|CT o&S 21677 ma /»^ 3m <br />