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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' --------------------------------------------- -- ----- (Complete in Triplicate-) Permit No...72:77<0 a Date . ----=------------------------------------------------- -- This Permit Expires I Year From Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549'arid existing Rules and Regulations: JOB,ADDRESS/LOCA.I N- ;� ___ ._-- -_ :___.CENSUS TRACT ----------- ------ - - -- Owner's Name_. L ''-"'�T �. rfii ) ` �--' yPhone ---- ----------- Addresst " _ - _ City -----Zip -y=------ -- - f T ` Contractor's Named --rpt-1.: ..__� - _ � ___ r_License .--- -_ /_ - ____Phone, _ - ------- { Installation will sere Residence Apartment House❑ Commercial ❑ Trailer Court: ❑ t Motel ❑ Other"' ------------ ------ Nukmber of living units_____ ________Nu ber of bedroo s , .,_-__Garba a Grinder-- :___Lot.Sixe.- - -_ - 1. _-- Water Supply: Public System and name.__ d _-�.__ - +� _--_ ---------- -- --------------------___Private �❑ Hard of Adobe ?. Fill Material r - ._If es,type-------------------------------- � Character of soil to a depth of 3 feet} Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ p ❑ � # �. Y r (Plot plan, showing size of lot, location of system;in relation to'wells, I5bildings,—etc:m•ust.be placed on reverse side.) r s NEW INSTALLATION:— 1\16"se_ tit tank or seepage pit permitted i fpublit f wer is�available within 200 feet,) PACKAGE TREATMENT [ j SEPTIC TANK p Size ' __ / --------------------- --_ ___-Liquid Depth __' ____.__-_______.� � F �� 4 r jj f + 4 Capacity,-�e/._1 f�,-I-TYP? �° '` . Materia ' ._No. Compartments :� ' Distance to nearest: WelIl � �.-, --------Foundation-_ -- __ �}-/-------Prop. i ine _ : _ __ _______________ ' LEACHING LINE .]-. No. of Lines_ /---- _._."--- --. sem' �- ------------ Length of each Lina.-_ __ �-__..:- Total Length'' I Material /�" ; -_-Depth Frlter Material- t_.___- Distance to nearest:FWe1!° - .F lt..Foundation_ =---- Property Line. '=- - - ----------- SEEPAGE PIT De t' _. F-4`_'Diameter - fir [ --------------------------------- Foundation - �] p r� � �___-_ _Number__- � � Rock Filled Yes ]' No'❑ I / . .. Water Table Depth. -- -- ^'-------:---W--- -------.Rock Size,-- --w•-' )---- -----� w Distance to nearest: ---__-Foundation--.-/ Prop. Line- -______- _____-___. REPAIR/AD �� --- ---_ �`. t � r DITION (Prey.'Sanitation Permit#::�.-----�---------=-''--- = -� _- "------Date--=----------=------'---------.--•--:- -------- 1 # � Septic Tank (Specify Requirements)_--- ------------- Disposcil Field (Specify Requirements){-------_ ------ - ----------------------- ---------- --------------------------------------- ----------------------- -- --------------'---- ----------------------- ----- -------------------------------- -----------------------:----=------------------------------------------------------------:--- -- ------ ---- ------------------------------ ---- ------------- ' (Draw existing and required addition on reverse side) M .1 hereby certify that•, ha"ve-prepared 'this 'application-and that_the:.work..Will be-done-in P-accordance with San•.Joaquin County Ordinances, State Laws, and Rules_ and Regulations of the San JoaquLo in cal 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,'-[--shrill`not em'pl-oy'any�oerson iri'such manner as t to become subject to.Workman's Compensation laws of California." CLARENCE'S SEPTIC & SEWER SERVICE Sign'fed : -------r---- -:. :Owner 263 So Oro! 5tacikar3, C 952 B ----- - ----- - -Title---- Ph.-453.32W-----Ccri Factor's-Lie,�?1-7. " ' - .., . - _)T._S1 (If other than ow4r) DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --- ----- -- - ------------------------------- DATE -- DIVISION OF LAND NUMBER. = ------------ -- = :_ DATE-----------------------------------.------- - - ADDITIONAL COMMENTS/_ - =-------------- ------ --- . ----. - ---------------------- -. ------------ ------- ----------------- ------------' - Final Inspection by:---- ---� -- --- - --------------------------S,e,N JOAQUIN LOCAL HEALTH`DISTRICT -------- -�--Date._fZ�-�--�---------------_------ EH 13 24 s 21677 REV. 7/76 3M