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FOR OFFICE USE: ....... APPLICATION FOR SANITATION PERMIT 76-33� ..............................:............• --• Permit No. (Complete In Triplicate) ............ ..................... ........:........ This Permit Expires 1 Year From Date Issued Date Issued ........:..�:7.. 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 existing Rules and Regulations: .IOB ADDRESS/LOCATION —/We �.I4 .-,4 1..46......�u sEu�......e-�.;10.e1 .� CENSUS TRACT Owner's Name - �� : [l e .! ivy.. ...... -� r.�.......... ... ............. ............ .Phone ................................... Address '- 45/7,,,o.0a..11°�.......................City .. /y/�� ............................ Contractor's Name .._ _.. CrP, ..................license # Phone.y.��.�o�.�s#'.. Installation will serve: Residence❑Apartment House C3 Commercial*railer Court ❑ Motel❑Other-.-*WAC.V.4.4dW.... Number of living units:............ Number of bedroorris ............Garbage Grinder ............ Lot Size ... WaterSupply: Public System and name ...............................................:........._.................................................... 0 Character of soil to a depth of 3 feet: Sand Silt-[3 Clay ❑ Peat❑ Sandy Loam-❑ Clay loam ❑ ld Hardpan 0 Adobe I3 Fill Material ............If yes,type............... ........... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse slde.1j NEW INSTALLATION, (No septic tank or seepage pit ,permitted if public sewer is available within 200 feet,) a PACKAGE TREATMENT .[ SEPTIC TAMC Size._ .. ..� .......:----•--••--•---....:...... Liquid Depth ..... .............. Capacity - ..... Type&.9fe s, . Material. sat.+ No. Compartments ..Z............... Distance.to nearest. Well e`er? .Foundation AP.... Prop. Line ... LEACHING LINE { ] No. of Lines .......3-------------- Length of each line....-4.Q............... Total Length ............� a 'e"'Q' Box ... Type Filter Material �....x..4. Depth .Filter Material ..fdP.................. ......... O Distance to nearest: Well .1. $..•-t---.-- Foundation ..,/Q---. ...... Property line�.'�.......... SEEPAGE PIT [ ) Depth ......... DiameterNumber ..._.... +.............. Rock Filled Yes No ❑ Water Table Depth •---•-4- ------•......:.................... .Rock Size .. .�,� .L. ...--- . Distance to nearest: Wel .. ..................f=oundation ./_Q. .... Prop. Line .. .............. REPAIR/ADDITION IPrev. Sanitation Permit . Date ................... Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) (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 Jeagvin County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health.Disirict. Home owner or llcen- sed agents signature certifies the Following: "II certify that in the performance of the work for which this permit is Issued, I shall not empiay any person In such manner as to beco blect toWorkman's Compensation saws of California.,, t Signed ..... 44.- .. --�.x. .......---•---•----. Owner 13y .. -- --e.C,...... --- -- -•--•----------- Title (if other than owner) F FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY ..—C-11 Y ....-[.....r1 '-----. -•-- [SATE T.. .!3 ..... ................. BUILDINGPERMIT ISSUED .... ................................. . ... ----- ...........---......------•---.....-.-.....--.........DATE ..........---.............................- ADDITIONAL COMMENTS ..-- ------- -------------------------------------- -...... ........................... ....... ............................... .................................. � Final Inspection by: -------- f... �;,.hs Y .........................................................................Date ....., / �`' ....._..... Edi 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M