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FOR OFFICE USE: FOR OFFICE USE:
<br /> �qM APPLICATION FOR SANITATION PERMIT
<br /> Permit No._ ---5E[Complete in Triplicate)
<br /> -----------------------------------------------'
<br /> ,. -.r..u....,�., * Date Issued_ ---------
<br /> ------------------------ This POrnit`Expires 1 Year From Da1el"ssued" --"""
<br /> t
<br /> Application is hereby made to the San Joaquin Local He6lth) 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 /> �� °.r_ CENSUS_TRACT --_-_ ------------
<br /> N1
<br /> ADDRESS/LOCATIC► _: �___: '.T_ _. F. ..
<br /> -----------
<br /> JOB, i ' �
<br /> Owner's Name----------- --'---- --
<br /> Qs� ---
<br /> --- -f ------.-,_._._Phone---------
<br /> --- -=. --------- -
<br /> y ,Cz ----------------
<br /> Address.-"., '-
<br /> '
<br /> ,
<br /> 047,
<br /> -, _ - Q
<br /> ItY� . p
<br /> Phone__icd!/� ense #Contractor's Name.+ .,
<br /> 4.
<br /> Installation,wilP serve: = Residence-P< Apartment House.❑ Corrimercial ❑ Trailer Court ❑ ¢
<br /> ----- ----------- ---- -------- ---- 4
<br /> . � �.. ...�.�.. -�:..,.,:. . .. -�I!Motel ❑ . .Other' :__. . ..�
<br /> sl
<br /> of living.units:,,.-./ Number of b Brooms`_�Garba a Grin w.-_ t,Size____.' _::�_._fi�-�------------------
<br /> Number ---
<br /> �/ g
<br /> Water Supply: Public System and name= .. - ' _._ Private
<br /> ;
<br /> Priv
<br /> Character of soil to a depth of 3 feet: Sand E] -Silt E] -Clay ElPeat ElSandy Loam ❑ Clay Loam [f
<br /> f �..
<br />' �• - 'Hardpan ❑ ` Adobe Ne. Fill Material._.__E�'lf yes, type------------------- -
<br /> (Plot plan, showing size of lot, location of system '1n relation to wells, buildings, etc. must be--placed on re{
<br /> INSTALLATION: .[No fic"tankor seepage
<br /> erse side.)
<br /> NEW
<br /> sep ' It`permiked if public sewer is available,thin 200 feet,]
<br /> PACKAGE TREATMENT [ I SEPTIC TANK [!j , �� Sislet ..___-_ - � '= -- Liquid Depth_ __:___ T-_-�
<br /> i -- m.-- `-NoyGornpaitme isCapacity i .Type --. Material_
<br /> `
<br /> Distance to nearest: Wefl ____ _._ "--iii--------------Foundation _.___._:-w-___:Prp: Line. _____ }___p�
<br /> 1f
<br /> / � � � ���aterlal Total Length.._ .__��
<br /> of / --------------.. Len tt`i+aof each line __
<br /> LEACHING INE, Do BoxLines_- T e Filter Material __ Filter _ /- ---------------------- --------------- -------'k---'
<br /> Depth Filt v!-�-
<br /> Distance to nearest: Well._ Q r, foundation__. � Property Line__-__ _______
<br /> SEEPAGE PIT Depthl:u- ____Diamete __Num er___ -----------_---- -__ f Rock Filled Yes No ❑
<br /> ti
<br /> Water Tabie Depth �_.= __ -- --# Ro !� ---------- -----
<br /> Distancetor`neare st: Well_ 1 :._____Foundation.__ __ . Prop. Line____,:��_ _.
<br /> REPAIR/ADDITION (Prev; Sanitotion'�Permi't#_'- _: "-- ' . .w---.. -` ---
<br /> -----------
<br /> ------
<br /> l
<br /> -- ---•-------- - ---='---=-.Date---' ------ --- ,..�-
<br /> ar ,� .,... - - _.
<br /> Sep#ic Tank (Specify Requireme ) _.__�_, -_- rt"-- -
<br /> ! f
<br /> ] pyo � - �-
<br /> Disposal Field (SpecifyRereme ts)t--- ------- - ,
<br /> Y__e-_-_- _T____ __ _ ____ ----
<br /> ---------------
<br /> __ _{________-------
<br /> ------------------------
<br /> i -- __________ .___ __________________ ----------------
<br /> (Draw
<br /> _____________.____ i------- __
<br /> b �
<br /> ---- --------- - --'---=--------- ----------------------- ------ ------- -- ------------- }�� '` ----_ -----
<br /> ----------------
<br /> � (Draw e l ting'and required addition`on reverse side)
<br /> r 1
<br /> I hereb certif that I have prepared;this.a lication-and'that-the work will be done in, accordance with San Joaquin County
<br /> Y Y P P Pp ,
<br /> Ordinances, State laws- and Rulesland Regulations of;thei San Joaquin Local Health District. Home owner or licensed�agencs
<br /> signature certifies the following:
<br /> "I certify that in the performance of'the-`work for which thispermit is'issued;"1 shall not employ any person iri such manner as
<br /> to 'become subject to Workman's,.Compensatio ,laws of California." s
<br /> e , CLARENCE'S-SEPTIC A SEWER SERL'IC}
<br /> Signed - ---- --- - .:_::- - 3 S an, Calif. 9520a
<br /> ` • .. ,.... -- . ... ;` -� Owner , _.e. 2ii o..Oro S ©cltt �'fi7171
<br /> f $Y'' - ---Title. --, Ph 4G3-3`209: Contractor's Lic.t"- -.
<br /> - --- -------- - - --- ------------
<br /> }
<br /> .__ ifother thd'n'owner] {----------------------------------------
<br /> -- .,_ i
<br /> s' 'FOR,DEPARTMENT USE ONLY
<br /> APPLICATION ACCEPTED. BY ------------ --------------- -" ------ e
<br /> " - = DATE t
<br /> ' - y
<br /> DIVISION OF LAND NUMBER _,_ __,DATE.4__.,_ _ _ _.#----------
<br /> L7
<br /> ...�. ....-- .,-- ,
<br /> I ADDITIONAL QMMEN S _..__ ._ ------------------
<br /> ------------------------
<br /> -
<br /> I -
<br /> -----A.
<br /> ------- --------------------'
<br /> ---------------------------------
<br /> Final-Inspection b [ w._ - r Y _-------------- _------------------ +Date . ---------------- -- ---- -------- -----
<br /> E 13 24 ' CC SAN J0AQUIN LOCAL HEALTH DISTRICT Fas 21677 REV.7he 3M
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