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FOR OFFICE USE: �� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------- -------------- - -- (Co �- mplete in Triplicate) Permit --------- / 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 compliance with with DCounty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAIION__oa_ _ __Q . __,,rQ-,_-__ _.._____ _____CENSUS TRACT---- ------ 11 - - - ------- ----- -- ------------------------- Owner's Name--- .- Phone --------- ----------------- Address------ o`�"�`- � City - ----------- Zip --------------------------- VS Contractor's Name6 _ UA___ _,___ _V_,4-VtreLicense #__k6_ /7 Phone__ NfJ 2- Installation will serve: Residence X Apartment House.❑ Commercial ❑ Trailer Court ❑ �J Motel ❑ Other------- --------------------- --------- ----- �y Number of living units:---- ___.---Number of he!,r� Garbage Grinder.� Lot Size-----l_ _ 1 'S^� -------------------------- Water Supply: Public System and name------ bye ----------------------------------------------------------------------------------------------Private ❑ 33 Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Q` Hardpan ❑ Aclobe < 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK �' Si [ l ---�--x3-------�lO'----------------------Liquid Depth.---� --- ------ - ---- Capacity_/.2 oType_ jt MatVL erial--- -____-- No. Compartments----. ------------- - Distance to nearest: --------------Foundation----/ -------------Prop'. Line--t5 r LEACHING LINE [ No, of Lines------- -------. _Length of eacp line_ _` ©__ _ __________Total Length._,_/ ---------------------- 'D' Box- -Type Filter Material-_ p _ De -� th Filter Material-----�-��---------------- =----•-=------------------------ Distance to nearest: Well_/_—_ ________---Foundation____1a----------------Property Line___,_'�__________________------ SEEPAGE PIT [ Depth_ _ -Diameter---IC -----Number------- _-------------------- Rock Filled Yes ` No ❑ Water Table Depth--------I--- -------- ------------------------------Rock Size-- 4t-------------------------------------- Distance to nearest: Well___ !' �C-�- _ ._ _ -mmdafion _L_Dv`P______.Prop, Line__ __ - ., REPAIR/ADDITION (Prev. Sanitation Permit#_ _3 _ _ -� Septic Tank (Specify Requirements)------- ' ------..- -' Disposal Field(Specify Requirements)-------------------- -----_----..-------------------.--------------•------• (Draw existing and required addition on reverse side) I hereby certify that I 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." - CLAREidCE'S SEPTIC & SE!,VER SERVICE Signed --------------- -- -- ---- ---- --- ---------------------Owner 263 So. Oro 4 c+ o- t ", tali-- -- --- ------- By- - ------------------------------ --------------------------- -----Title ---------Ph;_4fiT=3209 - --- - �--- �--� - Contrac�cr's Lic. 2 (If other than owner) - _ FOR PART NT E-ONLY .- APPLICATION ACCEPTED BY---- --- ----- ------ DAT E-------- 4 = -------- DIVISION OF LAND NUMBER ------------------------------------------------------------------------------- -------------------.-DATE.------ ----------------------- -------------- ADDITIONAL COMMENTS____ ________�__ - ---)-;/--------- ------------------------------------------------------------------------------------------------------------- ------------------------------------------- ---- ---------------------------------------------------------------------------- ---- ----------------------------- - - -------- ---- ---- ------------------------------------------------------------------------ FinalInspection by----- - ----- ----- - ----- - ---------- - - - - -------------------------------------------------------Date-----� ��-�----------------------- EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 3M