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FO OFFICE U E: JJ -1 -�3----------6w-------------- /J �0- =)------------------�' - APPLICATION FOR SANITATION PERMIT Permi+ No. ..,1 � � a (Complete in Duplicate) R /6 ----------- ----------------------- -------------------- .� 1 >l -------------------- ------ Year From Date Issued I Date issued'.-_------- - `r -.----.---- This Permit Expires 1 Ye -__- , 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. S49. �t JOB ADDRESS AND LOCATION.....-( z 10------------ -----••------------------------------------------------------------------------------- ,1 Owner's Name---------RA-6-------- It=u--1� `�---------------------------------------------.: Phone--•-••------------------ ------------------------------------------------------- •-----•---- Address-------------------- ---------------------------------------------------- Contractor's Name---- = .J9_JA_11t_A cA..,AX...... - Pha s== - Phone---- Installation hone Installation will serve: Residence loo Apartment House ❑ Commercial ❑ Trailer Court ❑' Motel ❑ Other ❑ Number of living uni+s:.__,----- Number of bedrooms _-,'ir- Number of baths _-I---- Lot size ---1.QD.`=-----..x------/__00------------------- --- Water Supply: Public system.P Community system [_1Private ❑ry1 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ Previous,Application Made: (If yes,date-.---- -.) No New Construction:'Yes No FHA/VA: Yes ❑ No X' TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----------*.....Distance from`foundation-------------- Mater ial------------------------------------------------- ❑ No. of compartments----------------------- -Size----- •---------------------.---Liquid depth-------------------------Capacity..------------------- . C `� - Disposal el: Distance from n -4-- --�-------------Length of each'line---.-------- nears st.well. QN-I Distance from,founda _ Q of tion.--- .'O-!.'-----Distance-_------.Width of trench--------------A-11P-of � r�Distance to nearest lot line a7-•- ------ ,) Type of filter material___ p�.-IC.-_._Depth.of filteri,m _ ... _aterial--- --.-).�"-----Total length------------------------ Seepage Pit: Distance to nearest.well---NAN.---.,-Distance fromsfoundation__-.-`{ --__-.D-sstance to nearest lot line--.-S--------. w Number of pits----------I.--.---:---Lining material_-�-----Size. Diamete -:---.Depth_..._..--_2- -'--_--_-_..-. Cesspool: Distance from nearest well--------------I Distance from;foundation---.----------------Lining material -_.__-------_.-----.----------_--- ❑ Size: Diameter----- t---------------------------tDepth----------- ---------:-Liquid Capacity----------------------------ga Q Privy: Distance from,nearest.well-...-.-----------------------------------'_--_---Distance-from :nearest building------------------------------------------ 171 Distance to nearest lot line------- --- N------------------------------=�-------------------------------------------•----------------------- : a Remodeling and/or repairing {describe:---- -! ----- = 't 'S� } "5--V-ST—Cli n-�----=-•------------ --•----•----------- ------------=----------------•-------------------•----------------------------------------- ., r # --------------------------------------------------------------------------------------------=--------•--------- -----------------------------------------------------------------••--------------------------------- 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. (Signed1c. -----• ''`'" ------�-"�- -- (Owner and/or Contractor) F - ,i: By: .--•-•-----... :` " . Title - ------==------------------------------------- -- ---------- (Plot plan, showingsize of lot, location of system in,relation fo wells, buildings, etc., can,be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY G� ' `'------------' RATE f- - �-� �-=