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r FOR OFFICE USE, L APPLICATION FOR SANITATION PERMIT Permit No. -.gL•.,44-1 . . - .. (Complete in Duplicate) This Permit Expires I Year From Date Issued Date Issued Application is hereby made to the Sen Joaquin Local Health District for a perm;t to construct and install the work heroin deserted. This application is made in compliance with County Ordinance No. 5499.. , JOB ADDRESS AND LOCATION-21.3..?...� a14 eAq ._'( ........._._..............._.__....__..._---------_.................... Owner's Namay� ...�if/�a fi..�rC+yr (......_....._..._.................._............. .. .............. Phone..............................._... Address... A�....._......�J..�... T..............._.._.........._..._. ...__ ....... .. _..._ ... ....... .__..._................_......... Contractor's Name........SJd./S,GC.._.5...... ............................................._........._........._..__......._...._... Phone_.............................. Insfallefion will serve: Residence ❑ Apartment House ❑ Commercial Q/Treiler Court ❑ Motel ❑ Other ❑ Number of living units: ..!.. Number of bedrooms AL. Number of baths .3•.• Lct sin ..................._.._.........._....................... Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table KPft. Chander of soil to a depth of 3 feef: Sand❑ Gravel❑ Sandy Loom❑ Clay Loam❑ Clay❑ Adobe M—Hardoan❑ Proviow Application Made. Ill yes,data...... ....... I No ❑ New Construction: Yes ❑ No Q.-FHA/VA:Yes❑ No 0— TYPE OF INSTALLATION AND SPECIFICATIONS: ) (No septic tank or cesspool permitted if public sewer is available within 400 festa„ Septic anlrr Distance from nearest well.................Distance from foundation..........._......Material..................._........................... . No. of compartments... . ........ ..........Size..........................._._Liquid depA......._.................Capacity....................... Disposal Field: Distance from nearest wellt6"a........Dfstance from founds}ion/..Q._.._....._Distence M nearest lot line...s;s.......... 04#,(W Number of lines.....I...... .. .................Length of each line.....4.0..'......_.....Width of tranch..�. ....0.._a.................. Type of filter material„A(Le.'Y....Depth of filter material..../..Q...............Total length.......4?.P...'........_............. Seepage Pit: Distance to nearest well/R x...:...... .Distencs from foundation....�A„..... .�.. .QQht Ice to nearest lot line #07-0... t o- Number of pits... ./........... ..Lining materia FV..b,C...... Size: Diameter...s3. ......Depth... ..-.. &.. ............... Cesspool: Distance from nearest well................Distance from foundation .. ................Lining material..................................... �J ❑ Size: Diameter. .. .............. ................Depth....................................................Liquid Capacity..........................gels. /K Privy: Distance from nearest well.............................................. ..Distance from nearest building..................._._.__............. 7 ❑ Distance to nearest lot line ........................................ .........................__..........._............._..................................... . 00 Remodeling era/or repairing (ou.crlbo(: . . . .... ...... ......................................... ...........................:..........._..._. .... _. 0 ...... .. .................. in .......................................................................................................... I........ __ __.........................._._...._.............................. . .. .. . ....................... ............................................. .................................................._....._._......_......................._..._.................................. 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Courtly ordinances. State laws, ,�redrules a d regulati s of the San Joaquin Local Health District. (Signed)_ ........ ..... 5................. ... .... (Owner end/or Confracter( . .. ............. ........... ... ..... By:..............................................................._............................................................_...(Title).............................:............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc.. can be placed on reverse W4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. ............................. DATE........../12l 6iS......... ........... __. REVIEWEDBY..... ..... . ...._.... _.._ .. . ., ... . ....... . ...... ...I.......................... DATE........................... BUILDINGPERMIT ISSUED... ......__.. . . .... .. . .. .. .......... ... . ..__. _ ............................... DATE......................................................... .. Alterations and/or recommerdafions:_ __ ......._ .. ......... . . _. _............................................................................................................. ............................................I....................... .. . ..................................................................... ......................................... .................. ........................................... .........._. _..._. .......-............ ..............................I..... ............................................................. .......... ......I...................... ...... . ... .. .. . .. . ... .......I... ...................................,......................................... .................1............... . ._. . _....... .. ...._....... ....................__.............. ........-........................._................ .................... - FINAL INSPECTION BY: �7�(n-C` Date.._, �/r. __ �. . ... ... .. .... ........ SAN JOAQUIN LOCAL HEALTH DISTRICT "1 1.Mannan AM .100 wut Oak wear 174 syrelaara Amar see wot oth$""I s..'Man,Cdnarnre lad),C.10.1.1a Menbsa,ca10na10 Mn.Callra,ala c0