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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR_;SANITATION PERMIT ---------------- ------- Permit No._ - ----------------------------- (Complete`.in Triplicate) --------------------- Date Issued-3-I.;--7� ---------------_________-------------_------------------- Nis Permit Expiresil year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit,to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ADDRESS/LOCATION �1 L� � L_ ' CENSUS TRACT---- JOB - - - --, Owner's Name.: : �_. - ---- Phone Address------ -----t'------------ ----`------ - City ----- - --- Zi ------------- -- Contractor's ----------- -- Contractor's Name. .V-�. .4- ._-.- . ,A.B,�r. rLicense # a�-�, 1 f s� Phone. 4.1 9 Installation will- serve: ResidenceA' Apartment House ❑ Commercial ❑ Trailer Court ❑ r Number of linin units:____. `.___ Number of bedro r g �.7 t oms-= Garbage Gunder. ._Lot Size---- _ '.- -h------------- --- i Water Supply: Public System'and_ name------ ._-_-------- --------------:--Private ❑ Character of soil.to adepth of 3 feet: ` Sand ❑ Silt E] Clay ❑ Peat ❑ Sandy Loam E] Clay Loam ❑ ` Hard'pari(].F. Adobe.V Fill Material.............If yes, type---:---------------------- ; k (Plot plan, showing size;of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW IN57ALLA1ION F(No`septic tarik or seepage .pit permitted if public sewer is available within 200 feet,) ii rt PACKAGE TREATMENT "Ca aSE ICTANK AN��,TYPE ----------- Liquid Depth 5-------------�--- p ate-rial__ !-c�f..�,No. Compartments..',..P------------------- Distance to nearest: Well_ --f"=-___�•-C ______=__._Foundation___�.Q__ ._______._._.__ r- �'o CA LEACHING LINE' No, of Lines. �...`.._...._;,..!!-Length of each line ----------- _____,Total Lerigth `/7 ------------ - : 'D' Box- -/ Type Filter"Materialr-�- Depth,FiIt�er Material._ .__ _. }---: ------------ -----------V 4 Di'gfanc-e--to_nearest WeIL� t'� �F undation-/a - -- Property Line--�,�-- � teeter_- s .f -- 1 � Rock F11lecl'�FYes Na ❑ SEEPAGE PIT Depth _ -lam Numk�er Water Table-Depth _ -- . - -- -- Rock Size;_ st Prop. )L in e�.__.I Di once . . F __ �� ___ eREPAIR/ADDITION (P : Sanitation Permif-# -- _ ' ----- Septic Tank (Specify Requirements)' - -_ -----i-, 4---_ --- f { ;: _------__-._--_-_•--_-------_ - Zir F �y•�. -.- -,,.,+• - Disposal Field (S eclfRsuiremnts). - ------------------------------- 7 = t ----- t ---------------------------- I -----'-- -- - .:_-------- -.---- ------------------------- ___________ ________________________________________-.___________-q_.___..___.-.---------_____.____.___...___._..____.___.._____________.___,.____.___._._.- F ____.. __.__..____ aw existing antic required addition an reverse sidel „� l , 1 hereby certify that I haveIIe prepared this application and that.the work-wili- be:done in accordance : th San Joaquin County V_'. 't. Ordinances,. State Laws; and :Rules:and Regulations of the San Joaquin.'Local Health District. Home owner or�licensed agents signature certifiesthe following: i Y "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 G r ,to become. subject to,'Workman's..Compensation laws-of -California.". s" # 1 ,CtARENCE'S SEPTIC i& SEV;,ER SERVICE Signed---- - = = Owner '263'So. .§ Y- 205 s . a BY- - � �` --=-Title l PIJr 46-3-:-2--09__. Contcaffr,,Licf:,Fr Z6711 t i 5(If other than owne" 1f FO DEPARTMENT USE ONLY r APPLICATION ACCEPTED B - -- `-------t��------- ----- ------------------ ---D E.-- ,`!s ir ----------- DIVISION OF LAND NUMB --------- ------------------------------.-- -E . DATE r ./ :U t ADDITIONAL COMMENTS - _ :�'` ------------------------------------------------------------! * 1 - y ------------------------------- ,� ---------- --- ---- ------------------- I -- - F --------------------------------------- - 3 - - = s '� --------- --------- -------- ---- ---------- --- =-� Date -- ._ -- -- Final-Inspection+by '-- ._. -- -- - 7 .. EF1 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7/76 3M