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FOR OFFICE USE: <br />......................................................... APPLICATION FOR SANITATION PERMIT <br /> [Complete in Tdpfkotel Penrth No. <br />....................................................... Date issued g�Q-77 <br /> .................. Tlds Penvat Expires 1 Year Event Oate Issued ... ..... <br /> Application Is hereby made to the Son Joaquin Local Health District for o permit to construct and install the work herein <br /> described. This application is made m cornplia with County Ordinance No. 54 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCAT! ... +�:_. ./. .. . �-�l•'. .............CENSlJS TRACT .......................... <br /> Owner's Name ........ .......... ...... ....................Phone .................................... <br /> Address ....�a....�1 .. r........ .... ..rClty•. .................................... <br /> Contractor's Name ..!�... .�..,,Q.f..�:�1�1...Uanse'iM o�. .`,Zl..`Z..7. Phone <br /> Installation will serve: Residence A'arM»ertt House J3 Commercial OTrallw Court 0 <br /> Motel 0 Other............................................ <br /> Number of living units:....... Number of ooms .....Garbage .. :. Lots= ..hoz.��.�-�.. ... <br /> r <br /> Water Supply: Public System and name ......OkVkAer . . 462 ..................................................Private❑ <br /> Character of soil to a depth of 3 feet: Sand D Silt❑ Cloy ❑ Peat❑ Sandy Loam 0 C3ay Loan O <br /> Hardpan O Adobe Fill Material............if yes,type.......................... <br /> (Piot 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK .... Liquid Deph f <br /> ,. ...... <br /> Capacity/ V.C4&ype ,j'�.1f. Gr [aterial.. .. Compartments ... . ... <br /> Distance to nearest: Well ..� ...CnJ��r.�......Foundation .Id.r. .......... Prop. Line .t� �... <br /> LEACHING LINE [ No. of Lines ......SZ............. Length ch line....&4. ... Total Length . �.......... <br /> 'D' Box ....r.... Type Filter Material .of Filter Material ..,!.7 "../....................... <br /> • , Distance to nearest: Well -)-V Foundation ......... Property Line .�—Z............ <br /> SEEPAGE PIT Depth oc. ....... Diameter Z� �.: Number .......o;................ Rock Filled Y" No Q <br /> Water Tabtr Depth ... .. .............. .......Rock Sire P./.. ..... . <br /> Distance to nearest: Well ,e-lw....A. ..A.— �f ounclation ....1 ... . lkop. line .. -. ........... <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ................ ...............) <br /> SepticTank [SpKify Requirements! ............................................................................................................................................ <br /> DisposalField (Specify Requirements ................................................................................................................:.................... <br /> ........................................................................................................................................................................................................... <br /> ............................................................................................................_............................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have.prepared this application and that the work will be done In accordance vA& San Joagvl t <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin LOW He" 01sidd. Hesse owner K Neer- <br /> sod agents signature certifies the followings <br /> "I certify that in the performance of the work for which this permit is Issued, I shag not employ any person In such mar-nor <br /> as to become subject to Workman's Compensation lows of Californlo." <br /> Signed ................ ....................:....................`...._..... . Owner CLARENCE'S SEPTIC & SEWER SERVICE <br /> By .............. r�,,(�.. �!� ' ............... 71t1e ----- • Er3 Sir:Oro. ...Stoc rr;EGET( 95?45. ......... <br /> �� Ph.463-3 <br /> 209 Contractor's uc_#26711.� <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.... ` ............ DATE ...... . <br /> BUILDING PERMIT ISSUED ........DATE ............................... <br /> ADDITIONAL COMMENTS . .f.. .,` ................................... ......................................................... ...I........................... <br /> ............................................. P............................. ....................._......•.........•......... .................•.•......-.•..•....................................... <br /> .............................. .. ............................. .. .. ..................... ........ <br /> Fina! Inspection by: ......... .Oats ... ..-,. _:/�...... ... . .......... <br /> .. ..-. ...... . .. ...... <br /> EH 13 24 2-68 Rev. � SAN JC AQ LOCAL HEALTH DISTRICT 8/74 3M <br />