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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------ - � (Complete in Triplicate) Permit No.-7F___,7,.5-2� --------------- ( --------- -- --- -----------------� Date Issued___9-�-_�_,?$� _______________________________________________.__ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health Disfrict for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance°No. 549 and exist' ,g Rules and Regulations: Dom._... .. ._. .._.. ,/ L ----- - - ---- ----- ` CENSUS TRACT ADDRESS/LOC N -------------------------------- JOB Owner's Name---- �'� 2r_�------- ----- - ----------------- Address -------------- -Phone Address---- -----7 ------- -------- --- ------ ------City--- ------------ -----------Zip Contractor's Name_ 1 ��i�` ' '�` `'�'� •rt�License #_oZ_ _��7 Phoney _ Q Installation will serve: Residence Apartment House.❑ Commercial E] Trailer_ Court❑ Motel ❑ Other_- --- --- --- -- ----- s� -____Number of be ooms____ arba e Grin er .Lot Size___ _: '_____. Number of living units:-__ _ ____ g P 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❑ Fill Material_---------If yes,type________________.__-______ S (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) S NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size_ P ---� �-----�--j�--------. ------liquid Depth -- =----4�, C a p a c i t yl4'4* (--!Type 4- { -Matey ial - No. Compartments e 1 Distance to nearest: Well.-__-___ ._______x__________Foundation>`:: Q __=__-Prop. Line___ LEACHING LINE [ No. of Lines_._._ -____ Length of each line.______ ------ - �� -----------Total Length_---��Q - ----- --- ti D' Box._._/_--Type Filter Material/C ____Depth Filmer Material____/Ir----------------------------------- Distance to nearest: Well----S --------( ----Foundation______ __ , G 61f--------------Property Line-----�---------------`------�--- SEEPAGE PIT [ Depthol., _rDiameter... �p _Number_______ __ _________ Rock Filled Yes No3❑ ✓, t rRock Size___ _ --------------------------------------- Distance Water Table Depth -- ------- -- ---- ---- � --- --- - Distance t "nearest: Well----- __---��----------- oundatlon_ __ �_ r__.'--.Prop. Line ___ .__ REPAIR/ADDITION (Prev. Sanitation-Permit#--------------------------------------------------Date_-----_--------------_---------------------) Septic Tank (Specify Requirements)----------------- - Disposal Field (Specify Requirements)-------- ----------------------------------- --------- ---------------------------------- - ---_---------------------------------- ---------------------------------------------------------------------------- -- -------------------------------------------------------- -------- ---------------------------------- ------------------------------ _ -------------------------------------------------------- s ---f (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 JoaquinCounty 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 tis to,become subject to Workman's Compensation laws of California." Signed-__-- -- Owner - --- ----- CLARENCE'S SEPTIC_&--SEWER_SERVIC@_-_-_ BY ( - - -- -27�ow - Title ----- (If other 263 So. Oro * Stockton, Calif. 95205 Ph, 463-IM9 Contractor's Lic.426 77 FOJt DEPAR ENT USE NLY APPLICATION ACCEPTED BY_______ _ _ �'' DATE ar ------------- -----=---------- ------ X 11 OF LAND NUMBER.________ _ _r - ------------ DATE ADDITIONAL COMMENTS - - ------- -------- ------- ------ - - ` --------------------- ------------------------------------------- ----- ------- --- -------•-------------------------- -------------------------------------------------------------- ---=------------- --- --- ----- ---------- - -- --- -- ----- _ y Fis►al Inspection by ( -- --------------- ---- -------- --- - - ------- -- ------------Date-- -� ----------------------- --d -_ ------ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT , P&5 21677 REV. 7/76 3m