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J _FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------- 7 7-16�S <br /> {Complete in Triplicate} Permit No.______._____.____.._ <br /> ` Date <br /> .•-•----------------------------------------------------- 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 Regulat, n <br /> JOB ADDR.ESS/LOCATI. NSUS TRACT <br /> 1 <br /> Owner's Name.------- :r Phon .1 <br /> ------------------------------- --- ---- ---- -- '- ----- ---�.: r <br /> -�s� - ------ -- ----- ,-�.w <br /> Address----------. .............City 'U` -------------------------Zip-Tyr. --- <br /> Contractor's Name[ ------- <br /> ----------- <br /> License '" �y-�,y am � • <br /> # ----------------------Phon f <br /> Installation will serve:i Residence Apartment House E] Commercial ❑ Trailer Court E] <br /> Motel ❑ Other------------------------------- ; <br /> Number of living units-----/ ---_Number of ydroo�msGarbage Grinder_-_�_ ,"--Lot Sizei.-/ r_ I�K ' -------- <br /> Water <br /> Supply: Public System and name-----a "f`:c�S "_-_�' '��- ----- -----------------------------------•---------------- ---------- ------------- ------PrivateMIA <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ .� <br /> Hardpan ❑ Adobe ❑ Fill Material__ ---------If yes, type________________________________ <br /> {Plot 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 ' ;~ <br /> [ 1 SEPTIC TANK [ Size- -- ---/`E_ir_____}�-•,t ---------------------Liquid Depth._�.�__ .__..-___ <br /> P Y-,?o ------Type ---- Material s No. Compartments-------- <br /> ------------ <br /> Distance to nearest: Well._4-,;�- r '__---________________________Foundation.____/V_------------Prop. Line--- <br /> LINE ,()✓ No. of Lines._:-------;_._, J <br /> --._ .Length of each line --- r --------------7ota1 Lengthf-j_=---- - - ---- <br /> t ' D' B,ox___+------- <br /> Type Filter Material_44�! ----Depth Filter Material__.+-X___.--_--.__-______ ------- <br /> I ____________________ <br /> f ._ i <br /> Distance to nearest: Well_ - ._____.Foundation.._,Fxee�---- --------- Property Line.-,.moi___.__-_____________- <br /> SEEPAGE PIT Depth _,C�_Diameter____________________Number.__..__.____.-__--_.____________ Rock Filled Yes EJ No <br /> J fi A <br /> 'Water Table'Depth-------I--------------------------- ---------------------Rock Size----------------- --------------- -------- ----- <br /> Distcnce to nearest: Well------------------------------------------Foundation-------------------------.Prop. Line------------------------- <br /> REPAIR/ADDITION (Prey. Sanitation Permit#--------------------------------------------------Date-------------------------- ------_-) <br /> SepticTank (Specify Requirements)----- ------------- ---- --------------------------------•--------------- ---- ----------------------------------------------- ------------------- <br /> Disposal Field (Specify Requirements)--------------- =-------------------------------------- --------------------- ------ ------------------------------- ------- ------------- <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 with San Joaquin Coun <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agen <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit'is issued, I shall not employ any person in such manner <br /> to become subject to-Workman's Compensation laws of California." .. <br /> Signed------ -1;.--- ---------- - Owner CLARENCE'S-SEPTIC & SEWER SERVICE <br /> / 263 So. Oro u Stockton, Calif. 95205 <br /> = 1,' -- Title. <br /> 11'h:X63-32ff9 C Tatra--— -- ---- - - - <br /> (lf other thanier) <br /> FOR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY-------- - ' DATE.----- = -1 <br /> DIVISION OF LAND NUMBER. -- ------- �'l Z~ DATE <br /> ADDITIONAL COMMENTS....[-�e-c,_,4------f r tr:►s �yi rr /� �t �„ rs�" r � s } <br /> ----------------------------------------------------------- --- -------------------- --------- ---- ---------------- ----- - ----------------- -------- -- -------- ----------------------- <br /> ______-__.-- __________________________________________-_____.___._____.-_____:._________-__,.___.____----____.____._-_________-___--___.______-_-.___-.--__ <br /> ____________________________ _____----_______ __ _ -_�____ _____ ---__________________..___--------------------------------------------------------- <br /> -____-__.__-_______.________._______.___... <br /> Final Ins ection b _ . - -- +� <br /> _. /l <br /> pY w - - ---------------------------- Date. I - ------- --- <br /> eN 13 2a 'SAN•JOAQUIN LOCAL HEALTH DISTRICT Fes 2r6» Rev. /76 3M <br /> EH <br />