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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT } - ------------------------------------------------ (Complete in Triplicate) Permit No.1-0 t_�/____-__------------- This Permit Expires 1 Year From Date Issued Date ---------------- ----------------- 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 Regulafions: JOB ADDRESS/LOCATION . 3Cf__ -_____ ?_ ___A_N.0 1__N_______ J.l__ .____-___--___CENSUS TRACT _- !_� 5 _____ //�� Owner's Name --------HER_B_�R-- -------J_'1�- M --=---------------------- -------Phone y Address -------------------2-I-3-------WALfq_UT S7r------------------ _,, . City ----- tpipt4--------------------------I/ Contractor's Name _A_N_T1-I0-_ S_p- - - __:License # ___ __-_ ,__ _--___-_- Phone r__.__ Installation will serve: Residence P11cp-artment House❑ Commercial-;❑Trailer Court Motel ❑Other ------------------------------------------- ` Number of living units:____!_____; Number of bedrooms ---2- -.-Garbage Grinder __ a_ Lot Size _ _CA19r7J�.-____.___.__ Water Supply: Public System arid-awne-.—A-------------------------------------------------------------- i't -----------------------•----•-----Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Cfdy Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ----------- y�s,type _________ ___ _____-._ (Plot plan, showing size of lot, location of system in relation 4 wells, buildings, etc! must be !placed on reverse side.) NEW INSTALLATION: (No sel:4thA)Ass&e ge pit permitted if Public sewer is available withih 200 feet,) I ri PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----_______________________-'---------i____ Liquid Depth __________________.___.___ Capacity -------------------- Type ___ ________ Material------------J_ No. Compartments ............... a } � Distance to nearest: Well -----------------------__.________:_Foundation ___f__ _- c�_ _._ Prop. Line _________ D LEACHING LINE [ ] No. of Lines ____ _ _____________ L ngth of each line T tal Length ----________________________ D' Box -_-___-___-_ Tye Filter M erial ___________,_______Depth Filter Mater a,(+ (Distance to nearest] Well ______ . Property Line ________________ ' -------------- Foundation ---------------------.. -Pro ------- SEEPAGE PIT, [ ] De th ______-___�__-----� Diameter ______-__-_____ Number --------------------------- Rock Filled 5�e�s 'd No i❑ Wa er Table Depth Rock Size ------- Distance toiji6p, est: Wel) u c ;¢�f ,F dnt. n �� -- Pro Line ______________________ REPAIR/ADD[TION(Prev. SahitationPeFF)nit ---------------------------------. '_ D e_�_� j-_�_.'L....__ ) Septic Tank (Specify fegdirements) ---------------------------- ,----------------------------- Disposal Field '(SpecL quirements) _� 11_'J_9_______,5�?________F[�D�______W__F-l_--i--_____-_1_ri_Z__o_Q_._h____ REFA ---T � = aQx=----------/oo--`---- gib_ -----E -------/-� ---------------------------------------------------------------------------- --------- ._.._._Jj) i-w_e4ting and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be dote in accordance with San Joaquin County Ordinapces, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents sitfinpttire certifies the following: • "1 certify th ip the perform of the work for which this permit is issue&,l shall t employ y person in such manner as to bec a Ubject Wor n's Compensation laws of California." Signed =j, -------------------------------------------- Owner .1 i y --------------- - ------ - - - -- -- By ------ -- - P--'---------------------------------------------------------- - Title ------------------------------------------------------ (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION AC,ICCEPTEDBY------ -__- ____ ----------------- DATE I.'" �' BUILDING PtRMti--tS8tifD-- ---------- _---------------------------- _ __DATE ADDITIONAL COMMENTS --- ----- --------- � 1------ 4'� i 1- �'X----------,= ------'1' �' ------------------------ -------------------------------------- - --- ---------------- ------------- --- ----- - - ------ -- ---- ---- -------- ------------------- --------------- Final Inspects --------------------------------Date --- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M