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FOR OFFICE USE: � FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No-----% "S------ ------------------------------ a-d-� 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 and install the work herein described. This application is made in compl iance with County (jOrdinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.------; _ : ___. 4-___t ✓� u---- ----"- !� ------- - ----------.CENSUS TRACT-------------------------------- Owner's ------ - -- -- - --------- Owner's Name..---------------------------- ------- ----.. - __ Phone_ - Address-- -07.4/ -C - -----14 � City-AP111- �� _ ------------------ _9"1� Contractor's Name''-"=� � '__<-" _ »,: _. .d-i� ,�,_t/t _ ,License #_ _ . . .°� "*Phone Installation will serve: Residence,& Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------------------- - r Number of living units:_____ ------Number of bedrooms__�____Garbage Gri der"' '__Lot Size sr✓__Xs-- ��x 1.,��_____:___ Water Supply: Public System and name--------- �t - �_----- ----- J1 - - ------------- --------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand Silt E] Clay E] Peat EJ Sandy Loam ❑ Clay Loam E]Hardpan E] Adobe Fill Material------------If yes, type____________________-_-________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) C` NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ 1+ �Si�GG___-----------------------------------------------------Liquid Depth._________________________ Capacity---------------- ---TYPe-----------------------Material-------------------------No. Compartments---------------------------------- (� Distance to nearest: Well-____-__________________________________Foundation__-___________-________Prop. Line---------------------- / r _ LEACHING LINE No. of Lines___ -I--_-_ ___-____ __.Length ofea h line j% .____ _ __.Total Length 4- _ i 'D' Box__ l_ ___ _Type Filter Materia __ --------Depth Filter Mar'eOial----------------- ---------------—- . :: ---_ __ --_-__-_ _________Distance to nearest: Well- "7_4i ___-foundation_„ &L----/____________Property Line__--- _________- SEEPAGE PIT �(j Deptl?,%,S�------ Diameter ----------Number-----r.__-:___ -____ ` , -Rock Filled Yes Na-❑ Water Table Depth----- ---------- k___ - -- ---- _. g ----------------- Distance - ----- --Distance to nearest: Well_ �l Foundation ✓ 0 .---------------- Prop. Line _ _ R, REPAIR/ADDITION (Prev. Sanitation Permit#-__________________________- afe::_:. _____ -------------------- :-- ) , Septic Tank (Specify Requirements)____-. __- Disposal Field (Specify Requirements)__ _ -h E .�iC -------------------- '`=f._ 4 -------------- ---------------------•-------------�----------------------------- f ----------------------------- -----------------------------------.----------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this a6plication 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 ,may. 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 & SYi►ER SERVICE Signed----- ,� ._- -- -- -------- ------ -- —---_----Owner 263 So. Oro 4 Stocktdl Calif. 95205 B A-� Ph.463-3209 ContrWor's tic,#26711] Y- -- --- ---------Title ----- -- ------ - ------ ------------------------------------ (If ---- --------- - - ----------- (If other than r) FOR DEPARTME USE ONLY APPLICATION ACCEPTED BY------ '�` DATE. DIVISION OF LAND NUMBER._____--. - - - - - - ----------- --- -------- ATE-------------------- ADDITIONAL ----------- - --- ----------- � c/C-` ------ °�- ----- ADDITIONAL COMMENTS___________ _ a�.. /?� 7 -------------------------------------- - - ------------------ ------------ Final Inspection by Date --7 ------ -- EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT &s 21677 Rev. 7176 3M