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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ...1 r—.—� __ .. _.. .. .. -.._ (Complete in Dup6cete( _...... _ This permit Expires 1 Year from Date Issued Doha Issued _...... ..!_. 6 't� Application is hereby mads , the Sen Joaquin Local Health District for a permit to construct and insten the work herein described. This application is mode in .c• thence wit County Ordinance No. $49. JOB ADDRESS AND 00c, SS ON.. .. t.��. ..a.�1d_ Owner's Ne" ...,.1. es>�_. . .. .. s:ve.............................._........... Address.../C.3.1 ..G.L_ �o.GQ- ................ .... --.............. _._.__............. _ _ __ Contractor's Name.................._....... . . ._......_.....................I............. Phan---- Apart . Installation will serve: Residence Apert I t House ❑qq Commercial ❑ Trailer Court ❑ M�III ❑ Other ❑ Number of living units: _!_... Number of bedrooms .,3 Number of baths ..y Lot ipe ...�f.4.2..... efL.+�._... Water Supply: Public system ❑ Community system ❑ Privet;& Depth ro Water Table ft. Character of wil to a depth of 3 feet: Send ❑ Gravel O�/Sandy Loam❑ Clay Loam[3 Clay❑ Adobe ef Hardpan❑ Previous Application Made: (if yes,dote... __. i No (Q New Construction: Yes 14 No ❑ FNA/VAI Yes❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available s "'p 200 feet. Se, is Tank: Distance from nearest well_......._. aten�c9 from sou efion..................MetLefieh...4r.'.�...lS.�..�3fs No. of compartments.......'). ..J' ..Size..!Y.X)..D..X..15k.iquid depth.......T.'..ry.....Capacity...f.3,Q4-- Disposal Field: Distance from nearest welL��ee from foundation.....3.Q.../,.Distanee to nearest bt P1ge•- ll� Number of lines.'......_... Length of each Iins. O�.�P..(.�..:.. dth of trench....�.�1:...._........ . C 1l .._.._... p Type of filter materiel...z..L. .. Wepih of filter material.../.p.�.�.........Totel length...w2.! ..........._..._.... Seepage Pit Distance to nearest well............._.._ Distance from. foundation........._.._...Distance to nearest lot ❑ Number of pits......................Lining material......................Size: Diameter.......................Depth................................ Cesspool: Distance from nearest well................Distance from foundation...................Lining material.....................................El j Size: Diameter. _ ............ .—Depth............................. .....................Liquid Capacity............................gels. ! r Privy: Distance from nearest well......................................... .Disienee from nearest building-...................._..._............ . I Distance to nearest lot ling_....�.................... .........................................._....------_................_.._..._.__... e Remodeling and/or re9airing,-(jserlbs)%.`.5..._ .d.G.rs _ _- _ - „""'• '-•......... '•' }ice. ......._...........25W.. .' _.:�:.?..:�..'�........... .. .. � . . ....... r� .. ........... — .: ... .... ..... ........_..........-......._............................ I hereby certify that 1 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 Sen Joaquin Local Health District. Sin s� 1ST b:!r?�...._L.SF.{tt r.'. ......__ ...........__._....... . ..........._ _ ...............(Owner and/orContractor) ( By:..................._..._............................._.......................... _ .._ .....__..._.. ..............(Title)............................. .._.. Plot P -- lan. shavinal g es of kat. location of system in relation to wells, buildin etc., can be laced en reverse sides lr FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.. . DATE rl.,.................. .... . r{�.Z REVIEWED BY ........_ . - . ... .. BUILDING PERMIT ISSUED................ .... . .... . . .... . .................... DATE Alterations end/or recemmendotions ...... . . .................................................................. .. ... . . ....... .... . ........... .... FINAL INSPECTION BY: Date /iZ- /' ` - • SAN JOAQUIN LOCAL HEALTH DISTRICT 130%..h A-.rlk.w auw. sop Wwt oak 3e..1 124 syre.er.s4»t 205 W...e.h au... ar.aNen, C.M.—I. Leal,Cdibmla MMtera.C0110e 16 Treq.Celll.rnla (i 9 nN15E0 8-59 ?` 5-62 .%1S