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APPLICATION FOR SANITATION PERMIT7 (Complete In Triplicate) Permit No. ... ./.:. .......... .............................................. This Permit Expires ] Year From Date Issued Date !:sued - .=.77 Application is hereby made to the San Joaquin Local Health District for a permit to consti4d and install the work herein described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regutationsi JOB ADDRESSAOCATi .oz. �?,-' .,--ti.le4l""4- ............................CENSUS TRACT .......................... Owner's Name ...... ........ ...4✓1... .I.............. ....'..Address ....._........... „� .... .... �. - --....... City . Contractor's Name ,~t,. .. - °I<.--._.. -.--License sF-.C•712.7.... Phone > ., . Installation will servo: Residence Aportrnent House fl Commercial❑Trailer Court 0 �7� sp Motel❑Other.. Number of living units:-.../.. Number of bildroorns ......Garbage tipinder .. : Lot Size •-- Water Supply: Public System and name .. ...................................................Private❑ Character of soil to a depth of 3 feet: Sand❑ Silt D Clay Q Peat Q Sandy Loam CI day Loam ❑ Hardpan p Adobe ' Fill Material ............If yes,type............................ (Plot plan, showing size of fat, location�af. systern,in.refation to.wells, buildings etc. must be placed an reverse side.! N!EW JNSTALLATIONr - (NOL septic,tank or-seepage pit.permitted.If public sewer is available within 200 feet,} PACKAGE TREATMENT`--.(..dry SEPTIC TANK Site...�.r .. .,X Liquid De p#h ... --r-......... Capacity e • Yp -- alexial._ o. Compartments a Distance to nearest:,Well - ...........Foundation . 0 ............ Prop. Line ...:r$.�...�..... 'LEACHING LINE No. of Lines -CI.....-------Length of each line.... :............. Total Length .,/. ........... E 'D' Box-.:,f Type'Filter Materlal ......Depth Filter Material ./F................................. Distance to nearest: Well �..... .. Foundation . .� .. .......... Property Llne .....�s. .... SEEPAGE PIT Depth 41..1.1_•_-..._.. Diameter -2.4........ Number ......�................. Rock Filled Yes ' No � — Water :Table Depth ...... ..:..........................Rock Size .C, ...`................ f .. - e / Distance to nearest: Well . d•=..1-�-� :� .:......Foundation ..f ....,.... Prop. tine -- ...:..... ----..� REPAIR/ADDITION(Prev. Sanitation Permit# ............................................. Data .................................. _ F Septic Tank (Specify Requirements) ............ . ........................ .......---................................................ . ................................ DisposalField (Specify Requirements) .........:............................. ........................................................ ......................... .... .... . ...............................................•---.......................................................................................................,.................................... . ............................. .....•--•-••---- .....-• ., ...................................................... � (Draw existing and required addition on reverse side) I her certify that I have prepared this application and that the work will be done In accordance with Sam Joaquin County Ordinonceir State Lawi, and Rules and 4tegulations of the San Joaquin Local Health District. Home owner or liven- sed 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 as to become subject to Workman's Compensation laws of California" CLAREIVCE'S SEPTIC & SEWER SERVICE, Signed •----.--- :.......c......... 17- FOR ....................... Owner 263 So. Ora Staci tan, Calif. 952fl5'Ph.463-3By ........... ....... — (. ..---........---- title .f other than awned _ DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .............C�.�./.�................................ .......... DATE ...�x`.77...:.........•... BUILDING PERMIT ISSUED .......................... ................. ......_........_..--•----•..............._. ADDITIONAL COMMENTS -.....,2_-' :�/ .....---• ,�+. -.... _. :_ ._ _ DAT .................................................----- .. . ........--------..... ... - ........ . ..... . ..-•--••......•.-----....•••... . ".......................... .... ................._............ Final Inspection by . . ........................... Dat@ . .'�.`, .............._... Et 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M