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FOR OFFICE USE: iPPLICATION FOR SANITATION PERMITd Permit No. ... ....... .... �t (Complel•ie Triplicate) Dole Issued......... 7� F ; ........ ...............•................................ This Permit Expires 1 Year From Des•IssmW Application is hareby mode to the San Joaquin Local Health District for a permit to construct and install the vAwk twain I described, This application is made in compliance with County Ordinance No. 519 and existing Rules and RpukNWrwr JOB ADDRfaS/LOCA 3G / CtLc- �. �"=`-r �.. ............. ............ _._ P J... "p Owner's Name .................................. :........Phan•'�b r3 p� 3fit; ��.... 7�c..-plc.., .. .......:/�s�+�/r/.......... ...... ...City ...... .O..:`. .Address . pJ Contractor's Name.. ...... --....................................lkerw� 7 installation will serve: Residence�partm•nt House0 Commercial❑Troller Cant fl Motel Q Other........................... �liZs6� • Gr(nd•r Lot Size Number of living v:'ts:..-�_... Number of bedrooms,.. Garbog ....-....... . ........................... tj s-t Water Supply, Public System and name ....... Chanxter of soil too depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat Q Sandy Loorno Clay Loawt❑ `* f Hardpan❑ Adobe❑ FIII Material.......... ,type .If yes ............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be pfoosd an ►worse �d••��J ;' NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer Is available within 200 leaf,) o h Size................................................ liquid DspMt ..........._.....- i PACKAGE TREATMENT ( ] SEPTIC TANK 1 J rt; � Capacity .................... Type .................... Material................. ... , Distance to nearest: Well .... ......Foundation ...................... Prop. Line............. LEACHING LINE ( ) No. of lines . ... .... ..... . . Length of eadi I(ne ....................... Tonal Length ........................... 'D' Box ..... ...... Type Filter Material I...................Depth Filter Material ........-. -- Distance to nearest: Well ..........I............. Foundation ........................ Prop" Line .. •. SEEPAGE PIT ( J Depth .. Diameter ................ Number ............................ Rode Filled Yes ❑ No .....Rock Size .........._. Water Table Depth '""" Distance to nearest: Well ........................................Foundation .................... Prop. line ................ REPAIR/AtJOlTION(Prev. Sanitation Permit t# ............................................ Date .................................. Septic Tank ISpecify kequirements) .......... ........-...... .................................... Disposal Field (Specify R gvirements► 2; ................................................. . . .... ...... . ................... .....and req.......... . . _.............._ ............._ . ........... ... .. ..... .... s (Draw existing uired addition on reverse side) I hereby certify that I hove prepared this application and that the work will be done In accordance with San J•s�ttMs County Ordinances, State Laws, and hulas and Regulations of the Son .1oaquin Leval Health DIsMd.Memo owner N now sed agents signature certifies the following: ew In sreb•tonnes "I :eMfy that in the performance of the work for which this permit is Issued, I stioll not enhpley any pen as to b e ub ct to or man Compensation laws of California." Signed l4.... . .... .. :... ... . ... Owner t -l �L �7�ftf ............... Title .....�w1�. _..__... _. . ......-.-......_.. By ....... .. .. (If other than owner) FOR DEPARTMENT USE ONLY _ ®-- . �- �— DOTE .....,7.... .... , APPLICATION ACCEPTED B . ... c- -. .1........................... . ........ .... .................... BUILDING PERMIT ISSUED ..._................................................................................._..:.. ........DATE . . ..................................... ADDITIONAL COMMENTS /�:« ................................................. .............................................................................. ........ ...... . . . .. . :::............- ::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::......::::::: :::::ate:� : ...::::'•::::::......... Final Inspection by G ,.. ............................... F�f 13 21r 1-613 V. SAN JOAQUIN IOCAI HEALTH DISTRICT 8�/u 3M