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FOR OFFICE USE: <br /> /1 .... APPLICATION FDR SANITATION PERMIT Permit No. .Z.V/ ,s— <br /> ... . _.....-._ (Complete In Duplicate) // <br /> -- - This Permit Expire t l Year R Date Issued Z- .A.A 3 <br /> Date Issuea <br /> this cep lice is hereby made to the Son Joaquin Local Health District for a permit to concruct and install the work hermn described. <br /> this application is made in compliance <br /> .._ .. GwithCoy.n.ty.�Ordinance <br /> rrdinance.QN/.�o:V. '5 <br /> 4.9t. <br /> K,t ADDRESS AND LC+CATIDN....L ....L',? <br /> 3wner'6 Name , <br /> !!�c . ............... <br /> ,i <br /> ...a... . . ..................._.................. ................ <br /> ......................... .................. Phone .......... _...... <br /> • ❑ Phone❑ Other..❑................ j <br /> :ontractor's Name........ <br /> ndel4}ion MIR Nrw: Reiidenu .... ............. <br /> lriSparfinent House ❑ Commercial E] Trailer Court Motel <br /> Number of living units: Number of bedrooms„?.. Number of beth%/... LotVdtw sift <br /> ...... ... .... <br /> Supply: Public system [3 Community system E3 Private�bepth to Wafer Table . ,> , It . .. ..... <br /> . • <br /> .horader of sal to A depth of 2 feet: Send❑ Gravel❑ Soddy Loam❑ ClayLoam 0a �,,,�� <br /> reviow ❑ Y❑ Adobe Imo.nerdNo❑ i <br /> ApplluNon Medf: pf yes, ...I No�New Construction: yes �f90 ❑ FHA/VA: Yes [Z,}.No❑ <br /> YPE OF INSTALLATION•AND SPECIFICATIONS: <br /> IN Sepflo tank ar eeypool Permitted N public sewer Is available within 200 feet.) / <br /> .optic Tank: Distance from nearest ural ,.Roe 0 Distance hom f n�dat)•on.- 0 <br /> No. of compartments. .. �' Idepth..Materia'.... ._.. 'p,c)"tC { <br /> Sixeeetaif..1!�i3tL<!'.L'S/�ti wd depth . .... ............. ._.... <br /> r i q P. .._. ._ _...._Capecify� .0(f_.. <br /> npoNl Field: Dirfonce from neern'well_.J�,� Distance from foundation..a tO. ,,,Distance :o nearost lot line..sr}........... <br /> Q/ Number of lines..... .........l.. . . .f Length or each line..�s.7! .. Width of lranch e�.'. ..�.......... ........ <br /> Type of filter material4ell Gn�.Do th of filter material..�(,�..,,,,..Total len tl... <br /> 01 P . ... .. .g 1,r�j..�r........................ <br /> eepagyPit: D:tanee to nearest oil...../_ P...Distance fro 1,�fo�yndetion...d.V. Di once to I•eareit lot linen .�.�.... l <br /> Number of pill....�...........Linin material.. ` yrnr ��yy���" <br /> P I�i:R.al ..$ift: Diemafvr.�(,'F Depth Zu7' b <br /> .esspool: Distance from nearest wellft .................Distance iron, foundation Lining malarial. .. ............. <br /> - . ..... . . . .. ..... . <br /> ... <br /> Cl Si : Diameter............... .. _ <br /> . epth......................... .. .... f� <br /> . D ....._ .. _ Liquid Capacity. .. ...._._ ._........geL•. <br /> rivy: Distance from nearest wall......_•...................... .......... .....Mitmice from nearest building ... . <br /> ❑ Distance to nearest lot line... . .. .... . - -- - - - <br /> emodaling end/or repairing (describe):—✓/��� � •�••.-���� ��� <br /> J �y... <br /> ....................................... ........... <br /> ........ILLY... <br /> ....... ..... ........ .. <br /> I hereby _ .. .. .. ... ._ ... . <br /> cert' that 1 have prepared this application and fha the work will ba dor,n in ecu <br /> rdinances, State L vs, and rules and regulations of the San Joaquin Local Hv.IfI. D stri:.t. ith San Joaquin Gounfy <br /> igned)... ......._ ......... ..�_�'1Yvh �.: <br /> By:..................._.—.-....................... �s Y�/l��E• ,"or Contract ) <br /> lot plan, showing sift of lot, location of system in rel to welt, buildings, efc., can be placed on revers„ side,: <br /> FOR D—EPA—R-TMENT USE ONLY —— <br /> PPLICATION AC':EPTED BY... - f,dam — -- <br />