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/• APPLICATION FOR SANITATION PERMIT Permit No. ......./- r / (Complete in Duplicate) Date Issued 1.....!"'••`"��I Application is hereby made to the Sen Joaquin Local Health District for a rmd to c$nityy�'e install the war he i deuri ed. 'tk This application is made in compliance with County Ordinance No. 549. C1 !.�/LQy �✓ JOB ADDRESS A 'LOC 0N..1:.1.I t�f�-`-.:1.�.��•;:_••--"... Owner'. Name ... .. .. ............................:........ .. ..... .. one Address......._ '............ --2... .... .. ............................._....._.................... `r ....: . ........ ..... .. v Contractor's Name .............................._.............................. ...................................... Phone on Installation will wrvs Residenci`, pertment House ❑ Commercial ❑ Trailer Court ❑ Moisl ❑ .Other ❑ .... Lot size ... Number of hying units: ..:. Number of bedroomx..3...Numzzzb,,,.,e111r of baths . I .Lfgr Water Supply: -Publ,c system❑ Community system ❑`JPrivate� Depth to Wafer Table �l.. ft• Character of soil to a depth of 3 fest: Sand❑ Gravel IA Sandy Lo,K a1m❑ Clay Loam❑ Clay 1-1 ,Adobe[:1 Hardpan❑ Previous Application Made: Yes [INo)C New Construction: Yes SNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or.essipool permiffed H s public sewer is available within 200 feet.) 4 C q+ Septi Tank: Distance from nearest well..p"J.Q.f CDistan rh fo ndCyfon....�.D Mate - x; M No. of compartments........X,�.. size...wz Y9. Liquid depth �......... Capacity. k,. ' l � �/� r� e •�'� f- ..... ....Distance to noarest lot ne �arn xs .Disposal Field: - Distance from nearest well c.7 r1-'E"-Disience from foundefion.,, Width of bench ' .. (' Ica' Number of lines......I........... .. ....t Length of each line..... .. .. r/... � ) l' '( Type of filter material ,S.TW'�lDepth of filter material....... .Total length f}�.Q..- See a Pit. Distance to nearest well Ja.�.f....Distance from foundelion...s fete a to nearest lot ng. _lQ ate 'e1 .Size: Diameter�x .....Depth 6 . Nembar of pits_. f ,......" - C spool: Distance from nearest well. +ante nom foundation...... Lining materiely .. ..L�gwd:Capacity.. -- 9 t � Size: Diameter......................................Depth.........._............................. _ r Y i Privy: Distance from nearest well............... •••.................1:stance from earesf build,rg - - ._._ '> Distance to nearest lot line................................................................. / low .... . . ...�--��•.,w�,��. - Remodel' g d/ r repairing Idesenl7p / .. L� . ��.i...ep�r+.n..f.,..+-. f/•�"'-� yo �c� � 'QL ::... ............................ ........._ .. .... . _ I herebycertify that I have prepared this opphcafion and that the work will be done in accordance with Sen Joaquin County ordinances, }eta ws end rules and regulations of+he San Joaquin Local Health District w S 9 (Signed ........ ................................................................. (Owner and/or Contractor) ......_.........................(rifle) .. ... r}� O CO tar) . By:_ ................ :.... .................................................... i' e) .. (plot plan, showing sin of.hlt,location of system in relation fe wells. buildings, eta, can be placed on rowne side). u- ?f FOR DEPARTMENT USE ONLYIITIsr. APPLICATION ACCEPTED '-""..""'-........ ... ..../.---.... II J .......................... DAfT�E.._ ..._ .:. 17aa ..4_, .� RLYIEWED BY ......... ................................... DATE ' BUILDING PERMIT ISSUED........................ "" Alterations end/or reaommendetiorm................. . . ,t f� ....�,.��.11.-.5....L... . O.J...... v fie.. (. .. xr .........................._ .. ... x. .. ......................................... .......................... .......... <yc� FINAL INSPECTION BY:................... ................................. \ "S lav' . SAN JOAQUIN LOCAL HEALTH DISTRICT a; ala Neth "C'•SMee/ 132 5"e"ne Street ti 130 South Ain.,;... Sfract 700 Wal Oak Stmt Meatless. Cdlferslc Treey. GI3en4 CeCforeto Indl, California $lo l/on, 3. E5._.9-2M io,2 Revised W4100 y.-'