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ar FOR OFFICE USE: i APPLICATION FOR SA11,11T'ATION PERMIT Permit No. ...... ..��v� . (Complere in _'uplfcato) ' Date Issued This Permit Ex .J/[.�/.L... phos 1 Year From Date Issued Applicaf on is h,reby made +,o the Sar. Joaquin Local Health Dis!rict for a permit to construct and install the work herein described. This application is rnde in compliance with County Ordinance No. S49. 1 �V,C JOB ADDRESS AND LO...CATION..A/....S.I.I.IXi�.� ..... ........ Owner's Name................ 4.C�..........JrT `A.TE(�. .. .... Phone................................... _..... Address....................+ cC'..:....1i5.:. ........1 .................— r.I. .(;T�.r1n!•i'> ..........--.......................................... Contractor's Name. - _GLAJI..%A4.�..................... . ..................................................... Phone.................................. . ............ ........ .... ......... installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Traiier Co•irt ❑ /Motel ❑ Other ❑ Number of living units: . / plumber of bedrooms z -- Number of baths �._ Lot sine .-P/I/C ri E O 6r-�.. - --- Water Supply: PubL. system ❑ Community system ❑ Private I—' Depth to Water Table .;70. ft. Character of soil to a de;.)th )f 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam 01--61ay❑ Adobe❑ Hardpan ❑ Previous Application Made: (if yes,dat, ? No V3" New Construclion: Yes ❑ No FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPEC IFICAT!ONS: (No septic tank or cesspool permitted .f public sewer is available within 200 feet.) Septic T.,nk: D;•.!ance from nnv w•1 wee! Distance from {ounda!ion. .. ........ .. .Material ...... C TIAjC No. of comrartmenls Size. ..... _.. .. ..Liquid depth (,apac;ty....... .. �..... Disposril Field: Distance from nearest we'I L•,Cl Distance from ,oundrit"on. ..1.U_... _Distance to nearest lot line.... t XCT I N Ci Number of lines _.�. Length of each I;nO. �.`>r �`+idth of trench ,�''�. ..��. ... .. t hA Type of filter material.. �'G�.F'�. .Depth of filter meto:la' j.`.I. Total length ................ Seepage Pit C;,slance to nearc•tf well Distance from foundation..................Distance to nearest lot lire..... ...... .. ❑ Narnber of pits Lining n,afer;al `lt.: Diameter Depth ...... Cesspooi: D;stancc f,om nr•orea well _ Distance from foundoi .on Liquid " g Is. Li m Lining ttctel l ❑ Ciame`.et Dr.;,fh iqu• ' Capacity. Dal. •cc from nearest building t Privy: D;'!ancf• :tom -ewes, wtll Dit!ance to r.ca•,,:t l.. lire Rr;mr�C..;,_q +lna,'or ...r•_.'•. � ...� // 1r - i i I her,by certify that I hive prepared this appl;cafion and that the work will be done in accordance wi',h San Joaquin County ordicanccs,�Stafa laws, and rules and rc•auiations of the San Joaquin Local Heaith District. (Omer and/or Contractor) (Signed) i<<.�. /. . << i... .l! U.- I �• .Z.r r\ <•, (Title) By: (Plot plan, showing size of lot• location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONL` 7 $; I , 1 i' DATE. � �= ---=-------- r "i ED E' DAT ! P.I_- . � r p 'JCr PER!'II SULC7 tA.-L_ Alterations and or recommendaficns: ^ i! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E A... :10:We+r CaL Sn....r 1]1 Sr.�-•cr..Sr.,.r•r 705 LYr•.r 4rh Sr,.rr Sio,lru n,Cu��larn,o � ' i