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r oo Pm . <br /> FOR.9OFFICE USE:,. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------------------- (Complete in Triplicate) Permit No--- - <br /> ---------/'-Z)---------------------------------------------------------- ! <br /> Date Issued- <br /> ------------------------- --- -------- <br /> ssued_--_-_---_--------------------------- --- -------__-_- This Permit Expires 1 Year From Date Issued <br /> I� Application is hereby made to the San Joaquin Local Health District for{a permit construct and.install the,work herein described. <br /> This application,.is_made.in..compliance-with-County Ordinance-No:-549 and'ezisting Rul s and Regulations" + <br /> JOB ADDRESS/LOCATION ,-" >- -+,[ .------ �• -." _t _ CENSUS TRACT ------ #--------- <br /> Owner's Name. F' '- - " .4----- t;f Phone - } <br /> - - ' �"i` j City '- ^'.�`" <br /> Address � Zip`" e! r i <br /> Contractor's Name_ r ICI-4 __ � ��, - � -- License # '--�-�_7 f_- __- <br /> Phone -------- <br /> _7_ q <br /> Instaflotion will serve: Residence; Apartment House.Q Comm erciah0 Trailer Court E]Motel Other---- -----=--- - - ---------------------- i ` <br /> ----Number of by rooms--c;4 ._-Garba, a Grind ` _ r.__ ' <br /> { <br /> Number of living units:_____ ____ _ g e�r�__ -..__.Lot Size '� �- <br /> Systemt_ ,�.• � '. r �t ,� E t— _ F-.Private <br /> Water Supply: Public -name ----------------------------------------------------- '____ __ ____ ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ .1 Peat L�k Sandy Loam ❑ :Clay Loam ❑ k '. <br /> Hardpan ❑ Adobe Fill Material..-_.+__._._If-yes, type____________________----------- <br /> (Plot <br /> _!___ ._(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: [No septic tank or seepags`pit p�� if public sewer is available within 200 feet,) } �; <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [; "f` Size----- ------------------------------=----------------------Liquid Depth------ <br /> Capacity- ---- ----- ------£Type----- ---- ---- ---- --Material___ __Material__--,--_-.------.---- No. Compartments '' -----------Dis4i <br /> - ---- ----------------- ------Foundation----�. ---------- ---Prop..Line-------;------ ------ <br /> LEACHING L-fNl= � Not ofcLinese to nearest:-Well=.•-_____, •,�' � � � <br /> �� F Length of each line----- e. �- -.----.Total Length t # i <br /> • 'D' Box y .___Type Filter Materia , °` __--.Depth Filter Material----, -�-fig------------------ - - k-----------. <br /> t <br /> Distance to nearest: WeIL-Y:k _3r c-' .Foundation ',? ----------------Property Line-____1�_____--------------------- <br /> SEEPAGE <br /> -______- l <br /> ---------- <br /> SEEPAGE PIT Depth cr f 4 ti. {' <br /> � p �.��.--------Diameter--�-.' ---------Number-'`�=-,.•'�---------f=---------�.�.�,.,.�.,.,..Rock,Filled_,Yes�'` No ❑ <br /> � Water Table Depth _t_ -- --�---- - _ ___-_-- <br /> Distance.to nearest. Well.- °undo n �1------ --------Prop-,.Line -A ,------------------- [ <br /> REPAIR/ADDITION (Prev.. Sanitation Permit# `____ '-- ___A_f_:' .-------- _,__ -Date_oo-i.=_.. -...___---- __---.____ } <br /> Septic Tank (Specify Requirements)------ ----- ' ., ... ='` ,;F - ------ ---- -- "`-"" -----r -----`---�-- �_ •-------- <br /> ------ - - <br /> Disposal Field (specify Requirements).-------- � --��--- -- - .'y- - � - _- - �= -�-_..- -- - ------- - --------- - <br /> - :---------------------------- __��..---__J,.-.'__ __.__-___-_________ _______________-_______________- __'----------------------------------------------------------- -- ------------------------------- <br /> -------------------- <br /> k-----'_-_________.- <br /> ____•--------------------- -•-----------------' - r - _ --__------------------------ ---------- <br /> (Draw existing and required addition on reverse side) ✓ ; <br /> hereby certify that I have prepared this application and that the,work will be done in accordance with San JoaquiiV 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 /> V <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 becomeisubject to Workman's Compensation laws of California.' ,�. <br /> I _ CLARENCE S SEPTIC `&'"SEWER SERVICE <br /> Signed---_ ____ - Owner 263 So. Oro' 'fStackton, Calif. 95205 <br /> _ _ <br /> s .. .�:�,_..._ . <br /> �. . r`!'.. -�- ` ��• • ------ 3-32}9-"GOpir <br /> [If-other"than-owner) - � -' 4., <br /> jam# <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = -----------------DATE <br /> ----------------------------------- -- -------------------------- <br /> DIVISION OF LAND NUMBER:------- .DATE____--.-----_----. <br /> ---.---------------------------------------------------'------'----'-------.._ ._.-------------j------- --- <br /> ADDITION_AL COMMENTS-�--�-n--,,----- ----------- ----------- ------------ :------------------ -------------- ------------------------------------------------------ --- ------�---------- <br /> { � ---.z .--""""i" j �� "__!"1t L !. ' ? ------------------------------_.------------------- ------- s <br /> l ------------------------------------ <br /> ---------------- <br /> -------- --ms's--- ---`�----------------- -- :�..__.--------- ----- -- -:---- -- - - --�------------ _ <br /> I . <br /> --------------------------------- - <br /> Final Inspection by:- ---------------------------------------------------------------------------Date. S ------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 Rev. 7»6 3M <br />