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r.. • »FOR OFFICE USE: s 3 APPLICATION FOR_SARIITATION PERMIT Permit No. ..._.. .. _..._.. ......... (Complete-In Duplicate) . This Permit Expires t Year From Dotal Issued Dote Issued ..7. ......_ .4$ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heroin described. This application is made in complianco with County Ordinance No. S49. 'l JOB ADOR=..- �TI�Iy �tV :a�7 .ye/ ,ply ,�u ..3.. ........_.._....... 'Owner's No �L£si./ ^�i�ilrf�..-_-_..__......._...............,..j...... / Phone..�.. _..... is Addrns________..� �✓.. f l _.............- �..,. 1!"s� l /�+115?..U7rX_4 .'9. . .9..,.,:.,,,.,,.,,., Pt+®E►a•..,.,..,,.,,.„,.... .,,....... Installation mill setwe: Residence ❑ Apartment House [3 Commercial ❑ Trailer Court ❑ Motel ❑ Other tlKa Number of..flving units:.. Number of bedrooms..+Number of baths ...»... Lot size ... ...... ..__..»._ WOW Supply: Public systemCommunity system C] Private [3Depth to Water Table ft Character of soil to a depth of 3 foot- Send❑ Gravel❑ Sandy Loam❑ Clay Loam Clay❑ Adobe❑ Hardpan❑ zPrevious AppGcafion Made: (If yos,dote...................) No New Construction: Yes M No ❑ FHA/VA:Yes❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pubic sower is available within 200 feet.) SW* Tank: - Distance from nearest well_./Il744.»Distance from foundation..Qd... J.aaR ?tr .... _ . .... q , � ... CapecityNo. of campartments......_ �' a th Disposal Field: 'Distance from nearest well...! Iw_ Distance from foundeti n.g .........Distance to nearest lot line ,/"�?C( . Number of linos..__....A.L.._... .... Length of each line. �.—.p 0 Width of trench:.....21.„.„... 'f Typo of filter matoriakS�OT .a epth Oi t”":Iter materiel.....lL... ......Total length....._. �.�.. » � •� .. _ a PrtK Distance to nearest well..._......._........Distance from foundo •an...».._...........Distance to nearest lot line..._. :.._._ C1 p .Number of p:h». ._.Lining materiel.......... '...._.Size: Diameter..._..................Depth.............. _... Ceu Distance from nearest well.._._- ,._Distance from foundation...................Lining n ❑ Size: Diameter... ........................ .Depth..._............._.........................:...Liquid Capacity........... .. .. __ el s.4... ^ Privy: Distance from nearest well... ..............»............................Distance from nearest building 13 Distance to nearest lot line............._......._.............-•-......__.... . ..�..._ ....._..._ g�'~»...... ...».� . _9 .... Remod I' a /or repairing (descri _ R :� _.. ' '' At __ »....._..._.: ....`..'�._`_............_._...____ is ._.._». .._............. ..... __.. I hereby certify that[have red this application and that the work will be done in accordance with San Joaquin County l p ordinances, 5+ate t ,s 4 d rag Iations of +he San Joaquin Local Health District. ! (Sign-../4''•�........... . .......... ..................................._....... .. .,.._.......... .. .. .........................»......_ .........._......».........- ..............(Ownor and/or C2!njt4 ) .._._.................(Title} ._......._._......_.....�.... 3 ...........(Plot pIa showing sae of lot, loea+fon of system in role+ion to wells, buildings, etc, can bo placed on reverse v FOR DEPARTMENT USE ONLY y APPLICATION ACCEPTED BY_.. d! '.....:......... . ....... ...�Ei _ ,fGd....... .. .._._ DATE:_. =I_D......am_............REVIEWED BY.......... .._.._.._.._ .......:_ ................._.._............___.........--......._..._._ DATE......._.....8UILOING PERMIT ISSUED .._.... �N .... _.._._...... .I,. .......» DATE..... _ Alfera+ions end/or recommondatioes:......ie/ll..ml2r...4.1 ........................................i....................................................... . .. _ _....�».. ........_......._...-..........._.................... ._.�. _................__.. .......... _.........._.. ._................................_.._..._._.._........................................... .............................................._..../.f......�........................................................_.........................._.........................._.................................... ... FINAL INSPECTION BY:...F�7!r../..,..._�f ....................._. Date........ `G ............ SAN JOAQUIN LOCAL HEALTH DISTRICT �f 1101 !.Magellan Ave. 300 Woof Oak Shoot 124 Syce ware Sf»N los Wort 1M Shoot LatiMo.coufwa:a Lodi California Honiara,Callfernia Tr f-� E.N.9 2M:.07 vao"rd/'w ary.CiliENnkO �l 3