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4�f �i�®FFlCE Usue <br /> .. .. ' "� APPLICATION FOR SANITATION PERMIT <br /> . � = , <br /> (Complete In Trlpllcate) Permit No. ....:3� <br /> 6..f.... :..::.: �... . ,. �,�7, <br /> This Permit Explres 1 Year from Date Issued Date Issued . .... <br /> Application Is hereby anode to the San Joaquin local Health District for a permit. to construct and install the work herein <br /> described. This application is made In com lance with County Ordinance No. 549 and existing Rules and Regutotionst <br /> JOB ADDRESS/i.00,4Tl �.1. ......I...................CENSUS TRACT .......................... <br /> Owner`s Name .......... ..... ... /} .. �.�. . ........ .Phone .................................... <br /> Address ...................... ,� :.1 _,gid.,- �.c�.�s -:.:..........'City .. ...... .................... <br /> Contractor's Name f..1 ...� 7 ' ... t-r �:1... .�l.,:iicense # :.t .l . .: Phone , .4....�j'. <br /> .. � <br /> Installation will serves Residence Ga;6partment.House❑ Commercial❑Trailer Court.-0 <br /> k Motel_❑.C±ther <br /> ............................................ <br /> Number of living unites..../... Numberof room .....GParb/age eider ..`_ Rat Size ... --- .�.�. ............ <br /> Water Supply, Public System and name ...................Private❑ <br /> �.*. <br /> Character of soil to a depth of 3 feet. sand❑ Silt❑ Clay ❑ Peot g ,,.„Sandy Loam ❑ day Loam ❑ <br /> Hrdpon 0 Adobe 0 Fill Material ....,::..' .if yes.type............... ............ <br /> {Plot pians;showi g siie_of_.lot,-location�of system. In relation to wells, buildings, etc. must be placed on reverse slde.1 <br /> E <br /> NEW INSTALLATIONS (No septic tank or seepage pit permitted if public sewer is available within 204 feet,) <br /> PACKAGE TREATMENT, { j SEPTIC TANK Sixe_ <br /> �. .., % '...... liquid Depth . .. .....:......... <br /> ft� . Capacity4TYpeMaterial... a. Compartments --C-----.f...... <br /> Distance to nearest: Well .. Tl . .....Foundation .. ��............. Prop. line ... ........ <br />'k 10000, el <br /> LEACHING LINE No. of Lines ......... a........... length of ch Jine.......# a.......... Total Length ........ <br /> 'D' Box ..` :. Type Filter-Material ....Depth Filter Material . .................................... <br /> • „ ; Distance to nearest. Well 4/:.A?--4.4K Foundation , O.e....... Property Line v i ...�....:.....::� <br /> _. <br /> SEEPAGE PIT Depth zN'7;�.......... Diameter a :t ..r... Number __...,t`..............:.. Rock Filled Yes No <br /> — <br /> WaterTable Depth .._ ....._r..... ...................Rock Size . <br /> 11 <br /> Distance to nearest: Well .?Z0f� .. ......Foundation ...Ila........ Prop. Line ..'. ............ <br /> REPAIR/ADDITION{Itrei. Sanitation Permit ..........'.................................. Date .................................. <br /> Septic Tank )Specify Requirements) .................... .... ...... ..^...� ..: .............._................ <br /> 'Disposal Field (Specify_Requirertinents) ......•-••-........ ...................................`� ...._.............................................. <br /> ............. .............................---....._:..... . .:....... <br /> ..........._........._........._.............................. .................----........:... <br /> i(Draw.existing-and`.re..uired addition-on reverse side) <br /> I hereby certify that I have preporsd this application and that the work will be donsi"In accordance with San Joaquin <br /> County Ordinances, State Laws, avid Ruler and Regulations of the Son Joaquin Local Health District. Home owner or Ilcon- <br /> sed agents 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 /> as to become subject to Workman's Compensation laws of California.” <br /> Si ned .. Owner .ClARENCE'S SEPTIC & SEVER SERVICE <br /> 9 ....... --.......... ........... F0 4 Oro Stoe;;, ,� il <br /> By --.......... , ------. title ........ i' '. . s�zQS <br /> _ #other than owns ' ' <br /> ! FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ........................ :a. ..........-----..... DATE .....S._ ._.L. ..:7.. ............ <br /> . DATE <br /> BUILDING PERMIT ISSUED -------------------------. ..........................-.............. <br /> ADDITIONAL COMMENTS .... <br /> ........................ ................ .. .... ....... . ...... ....................................... ....... ......................... <br /> ................ <br /> .........................--- --- .............-- .-•-.. ../ .... (.. ...'................ ..... ' <br /> I. ..... <br /> FinalInspection by: ...---•--•-- ......••. --••--..... ..... ..... ............ ....................:..............................Date .. /.. ..........Eli .. <br /> 13 24 '6 - j SAN JOAQUIN 1� EALTH DISTRICT 8/7h 3y <br />