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M <br /> FOR OFFICE USE: !1 FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ' ff <br /> -------------- --------- -------------------- - 13 Permit No.__.W'1- ----- <br /> ' <br /> i (Complete in Triplicate) : <br /> �II 1 Date Issued_Z`_,�__V-_7F <br /> _________________________________________.._._____.F.__ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: # <br /> JOB ADDRESS/LOCAT101V -.+'' }a..--: �'•'`'' �# .. � _CENSUS TRACT--------------------------- <br /> IE 1 <br /> Owner's Name------ ioLdyr f�i :�: t � �--,sc-- ---- Phone-- - i <br /> .. r <br /> Address.------------ -- --sem = -,A. City-sic -------------- !t.- Zip--- --- <br /> Contractor's Name. - _ _ f �- . ► _.License #- f' Phone ` <br /> �� _ ----- - <br /> JA <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court- ❑ <br /> I <br /> -.i� , ....... Motel.❑ .Other-.-_::-.."------- - - --------- <br /> ---- <br /> ---=-- _ t <br /> a <br /> Number of livmg..urlits:___} .__ 11'Nurriber.`f drooms,�: '__Garbage Grin er`` /r Lot'.Size____ .E '' .�-- ._______________.__ <br /> ' ' l t <br /> Writer Supply: Public System and name � ' - -iS'"� = F F = -__•__- .=-1--- __------` Private ❑ I <br /> Character of soil to a depth of 3 feet Sand ❑ Silt E] Clay E] : Peat ❑ Sandy Loam E] Clay Loam E] ! <br /> -Hardpan E] Adobe {y It <br /> Material -_--If yes, type---------- <br /> R - 14 <br /> X14 <br /> {plot plan, showing size of lot, location of system in relation to wells, buildings,,etc.'must be placed on reverse side.) 1�+ <br /> NEW'1NSTALLATIONt"`ANo septic'tank or"'s`eepage�pit perrrlitted`i pubJ1 sewer i pvailable'wifhin 200 feef;) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK : Size -�_____________ _ ' --------------Liquid Depth----------- <br /> Ca acit `TYPe ---. - . --Material- ------- = '_No. Compartments '-------------------------------- <br /> - <br /> • <br /> ._ . .Distaneei.to-nearestWell ~~ . Foundation "PropLine^ —"t______ __-.{ <br /> LEACHING LINE [, No of,L nes,_ ,'#_ ,. _ 1 ength--d each line_ °� ' ___Tot ten th- ~- __.-------------------- <br /> 4 $' <br /> - -- -- = - <br /> d - yp- Iter Material �`'- ___' __.Depth Filter Material /°______ _.--------------------------------------------- <br /> F <br /> _ __ <br /> D�Box__ T e Filter j� .� �.. _ ..._ .._., rf ,._... "i -i t <br /> ­Well <br /> � . <br /> f Distance to nearest: Well _ Foundation __._ _Property Line____ _________ k _- �3 <br /> t. SEEPAGE PIT De fh �` �.'�Digm t r 4- V " Number"`_ _ _ T <br /> p -�. Rock Filled�Yel No'❑ <br /> Water Table Depth Roc"k'Size _ --'~----- ------------ <br /> --- f <br /> yip <br /> Distance to nearest:Well - ::- f _-- .Foundation ` '------- Prop Line_._.-.----------------- <br /> REPAIR/ADDITION <br /> -----_ , .REPAIR/ADDITION (Prey:Sanitatlorr Per #__'. -------__:___r'__.__'_____°Date_._.____:___ _______. ____); <br /> � it <br /> Septic Tank'(Specify Requirements) - tea* " '--r_______-- ---- <br /> = I - --- - <br /> Disposal Field (Specify Requirements)_.._ __ _________ __ _ _____.__.. <br /> -----=------------------- -- �.^- <br /> -------------------- _----- ---- --- ------------------------------------ -- - - -------- - - -- - <br /> s (Draw existing and required additiomon reverse side) <br /> I hereby certify that'l have prepared this-application and that the work will-be clone in accordance with San Joaquin tCounty <br /> s Ordinances, State Laws, and Rules and. Regulations of the San Joaquin Local Hecilth District, Home owner or licensed agents <br /> signature certifies the following:) .?TZ <br /> "I certifythat in the • � � 3 ic• ¢.. s <br /> performance of`the work fo+:which this permit is issued;Tl-shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws,rof_California." <br />-Signed Owner S ICE _ <br /> CLARENCE'S SEPTIC_&.. EWER.SERV j ` <br /> r F+ --- - r <br /> By----- c <br /> �'= = Title. , S-- Oro----- Stoclitnn, Csti#: 9 213 <br /> ____263' <br /> :463-3209 Contractor' <br /> Jif othe n o er) s Lir,.,J`26717t '# <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION <br /> PLI A OF LAND <br /> BY---_-_I�.-- k. _ _ �" DATE -� -- - -- - -------DIVIS <br /> ND NUMBER,---.IM------------------------------ -- --------DATE.------.- ----------------` <br /> ADDITIONAL COMMENTS--- ' - - --------r - -- c <br /> ------ -------------- -------- ----------=--- --------------- ---------- = ---- <br /> F <br /> --------------- ----------------------- _- ----------------- - <br /> Final Inspection by:----'. ----- - - -- -- -"--- - Date---f, ' ., ^ <br /> - ------- - -- -- ----------- <br /> - ------------ ---- <br /> EH 13 24 I SAN JOAQUIN LOCAL.HEALTH DISTRICT F85 21677 REV. 7/76 3M <br />