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k <br /> e <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> Y' <br /> 4, 7 No. 7 7— 73 3 <br /> iComplete in Triplicate) <br /> Date Issued J�/s 77 <br /> This Permit Expires 1 Year From Date Issued L— <br /> 13e to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> ­ide In compliance with <br /> Coun•y Ordinance No. 549 and existing Rules and Regulations: y <br /> /V;.2f? �'v -2{r /t�d�� CENSUS TRACT T <br /> AT�ONZi eeyy . <br /> iga ��' Phone r�goZ� <br /> d 0v0- 4f. �/wY �9 city JP,yaan '- .Zip. <br /> C'�C.�h.J,we,Ct Y J► �4 �1 r License # d1r. ,717/ Phone 7-P, <br /> S11.,E> Residence ❑ Apartment House ❑ �ommerciol Trailer Court <br /> Motel [] Other <br /> o ts: -i&?- Number of edrooms 49"Garbage Grinder -1t ' Lot Size <br /> S Private <br /> c' b'�,. System and Home e..� <br /> or sol to a depth of 3 feet: Sand❑ Silt 0 Cloy❑ Peat❑ Sandy Loam p Clay loam <br /> Hardpan ❑ Adobe j] Fill Material If yes,type <br /> ;h•,w ing size of lot, location of system in relation to wells, buildings,etc. must be►placed on reverse side4 <br /> INSTALLATION: (No septic tank or seepage pit permitted ifpublic sewer is available within 200 feet,) <br /> V TREAT�4ENT ( j SEPTIC TANK � Size 4A k-10 Liquid.Depth <br /> Capacity�QQ�ype� Material o. Compartments <br /> Distance to nearest: Well.. Foundation & Prop. Line v <br /> -NG LINE No. of Lines Length f each line �04 Total Length <br /> i <br /> D' Box l Type Filter Material Depth Filter Material <br /> Distance to nearest. Well 'SWFoundation �� Property Line <br /> rAGE PIT Depth c7.r oe Diameter 73,0.* Number /10 Rock Filled Yes No <br /> • i <br /> Water Table Depth � r Rock Size <br /> Distance to nedrest: Well 40V Foundation Prop. Line <br /> REPAIR ADDITION (Prev, Sanitation Permit Oore ) <br /> Tank (Specify Requirements) <br /> 0 ;posbl Field (Specify Requirements) <br /> ;Draw ifisting and required addition on reverse side) <br /> hereby cerlify that I hove prepared,this application and "t the work will be done in accordance with San Joaquin Coun <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agent <br /> signature certifies the following: <br /> 'I certify that in the performance of the work for which this permit is issued, 1 sholl not employ any person in such manner as <br /> rn become subject to Workman's Compensatioe laws of California." C , .,c •�cR CERVICB <br /> i Owner 1. • ., �n•�, cs�d 95705 <br /> Title r., . . r..a::a ICr . lit,A'oll7� <br /> (If other thanowrte <br /> j�0FJ <br /> FOR DIPARTMINt USE ONLY- <br /> \c'i Fr1ED BY •t_ .�,1'�4tr�. /0/L1 DATE ---=7 / ""/ 77 <br /> nr;n NUMBER / DATE <br /> - .. • Date � • <br /> SAN .•''•/+:1UI�1 iOCAI. HEALTH DISTRICT rrs 21677 etv. me sM <br />