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r FOR OFFICE USE: FOR OFF"'USE: """' APPLICATION FOR SANITATION PERMIT .......................• ---------- ----- -- (Complete in Triplicate) Permit N 2fl? .......... ---•-------•----- 7 `' Date Issued.........`.__./ ........•-..--••......................................... This Permit Expires 1 Year From Date Issued Application is hereby made to.the San Joaquin Local Health District for a permit to construct andinstall the work herein described. This application is made in compliance with County Or i ante No. 549 and existi Rules and Regulations: JOB' ADDRESS/LOCATI ©l T. _.7C... ..CENSUS TRACT................. _.. Owner's Name.... ....._... _........ ..... G�"s't .... _ .. .. ....... •-..:---- ..... .....:. ....__.... ---Phone. Address....:.....7�e City ZIP _. . 01 Phone, .. .... :Contractor's Name.- ---. -- .4-_ - ---.--.. ..�.. rc(/I,.,,��f 'License Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other.... . . .............................. Number of (iving.units: .......Number of be rooms._ arbage Grinder.._. Lot Size__ ��'._.L .._. Water Supply: Public System and name. .._.Private ----- ---..._. Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑- Clay Loam ❑ Hardpan ❑ Adobe 9 Fill Material_ .... ....If yes, type......................".. ----- (Plot .._(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION, (No septic tank or seepage pit-'perrm. itted if ubllc sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] �.X fS$ize � Liquid Depth. ----... ...---- - -•-•--. Y- -- _ . Capacity ..._..._TYP e.... ........ . __Material _ -- ---... .........No. Compartments-------_- ."..--------.-"-----_ P _ [distance to nearest: Well.................. ........ .........aFbundation....... -- .............Prop. Line.................. LEACHING p -- .... Total.Length .. ._.Q_......_......__. 'D' Box.-..*&.-_Type Filter Material. _-_Depth.Filter Material....../?.................._............I—----------------- el Distance to nearest: Well �:_..�........ Foundation _.:�4 � l. __. . .__.Property Line...Uf7...................... SEEPAGE PIT Depth:_:. -Diameter....1 ..__._.Number._...._/...................... Rock Filled Yes Water Table Depth---- --/ -a.....---.-- ----._------------------Rock Size..... ------- .................. Distance to nearest: Well.._..Ary........ .................FouQdation......l0 ............Prop. Line."-._._..... ...__.......... REPAIR/ADDITION (Prev:Sanitation POrmit#..........,........ .............'Date- ..___.-------------. .---...-- ----------) Septic Tank (Specify Requirements) ..._ ...... _-"_... ................ .... --- ---- ---Disposal Field.(S ecif RLuirements} ' ` ........ -- = --------- ........... ------ - •......---- .......... (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "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 to become subject to Workman's Compensation laws of California." CLARENCE'S SEPTIC & SEWER SERVICE Signed.--- - ---------- ----- -------Owner 263 So. Oro vL Stocktar, Calif. 96205 7 BY............. ......Title..... .-- w-- Ph.463 3209_. C,,ri;d Or's Li-,. Zp/17.1. (If other than ow Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-••- -- . . .----- .. - - ------------------•----....------..DATE ....... ..... DIVISION OF LAND NUMBE . -- .----------------------_--:--_-----_-- -- --_-DATE.------------- --....... __----------- ADDITIONAL COMMENTS-----------------_ --------------.-......-.._._._. ..------•-----•-----..----- ••--------------- - ---- -- -- ----•-•------••--------- . ............----___.......................... -----------•------------------- ----•------ ----•- ........--- --------------•- ---------.--------------- --...- ........ --------- ........... ........................................... ..................................................... .............*----------------- -- --- ....--•- -- •-----............................... -----... ---- Date...-.,.----- --- -''� --------- ._. .....•---- Final Inspection by: o -�`�_ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 3M