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l FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT .. Kompleteln.Triplicatel Permit No. !� t ........ ..-....:J� ..........:�}_.( _........ _. (. V .. Date Issued f l..i.Q...t..�....................... �Th'iss Permit Expires 1 Year From Dab Issued �-..... __ j Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described.`This application Is made in compliance with County Ordinance No. 549 and a sti R s�cnd R9gulations: I / .108 ADQRESS/LOCATIO f _... -•----......_ Owner's .Name '`... .--1.......-....:.................:•.Phone .................................... Address . - ...... ` --- City .................................. installation will serve: Residence' .............License •� r -. Phone dence Q Apartment Houseo Commercial OTrailer Court O 1 Motel 0 Other Number of living units .. ._. Number of bedroon4 "r.bo.ge Grinder Let Size .../. Water Supply: Public System and nam® � irate pP Y� ' Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay 0 Peat j] Sandy Loam p Clay Loam ❑ j Hardpan 0 Adobe 0 Fill Material ............If yes,type .... 1 6(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed'an an reverse side.) NEW INSTALLATION: tNo septic tank or seepage pit permitted if public sewer is available within 200 feet,! t� J PACKAGE TREATMENT ( J SEPTIC TANK; J Size.--• -._. 0.......__ Liquid Depth ._ Capacity _110,0— Type - ......... Material.. No. Compartments .._. .. Distance.to nearest: Well ... ._ ...D................Foundation _1.4).......... Prosp. Line ... ........_----- LEACHING LINE ( ] No. of Lines .......� Length of each line." /� Length fi`'`t.... -- g ..�.....__�. Total Le tth ro....... -------- _. 'D' Boxy-pe Filter Materia! ...� . .... .D pth Filter` Material _/ Q............. •----_•-.._ Q Distance o nearest: Well ........................ oundation ......._. .._.....:.._. Property line ........................ / SEEPAGE PIT O Depth - 116""- . Diameter Number ...... .......... Rock Filled Yes ""' No ,. Water Table Depth -------- ....................... Rock Size ' 1 ........_ , 1` Distance to nearest:Wel!' �_ ..._ .Foundation ......... Prop Line ...................... rt REPAIR/ADDITION(Prov. Sanitation Permits#•` .......... ...._._............... .Date .`-..._._... .. Septic Tank (Specify Requirements) ' f t ., ....:. i ........................_._".................----- Disposal Field (Specify Requirements) .................................. ........•----------...........--- "-`-= .......------•-------.--••-•---•--•-•-•--•------•••••-•-- 1 .................................... ----------------------------- ._..".. [ _ i V~ � (Draw existing and required addition•on reverse side) I hereby certify that I have-prepared-this-application and that the work will be done In accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health:District. Horne owner or len- sed agents signature certifies the following: 1 "J certify that in the performance of the work for which this permit is is Fad, I shall neten+ploy any person In such manner as to become subject to WW rkmaWs-Comppnnssation laws of California." f Signed - O r SBy ..-- i..... If o hon w e .......................: ........... .................� er ne FOR PARTMEN VSE ONLY APPLICATION_.-}YCf 3Et3-B _ - . .C+" .............---...... ------..................---....+r..:......_DATE .__-.....0$ •--- - BUILDING PERMIT ISSUED .................... ... .DATE ............................................ ADDITiONAL COMMENTS ...............--- l ..... •----...._...--•....-•---••............. _......................... ....... ti;_.. Lina! Inspection by : t• ..._.... ��._...............r` ....^Y Dat .._.. :,,......... .. . . ....... . Eli 13 2II 1—b v. 5}�i b SAN J{SAOU#N LOCAL HEALTH DISTRICT - 8�7h 3M - i