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APPLICATION FOR SANITATION-PF-W.-IT Permit No. ____2__l__-L__G W--� (Complete in Duplicate), EXPZRTIS ONE 1EAR1.7-Ak � �+ - •Issued ___-- .:RJ1A DATE Dat Application is hereby made to the San Joaquin Local Health District for a permii�10 e�rstrfnd�l'n a ork herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION.----- s- a r `�' ` V ' �� --------------------------------------------- ---------•----------------------- Owner's Name--- _-- -'_----- V4 1 Phone--------------------•-- Address------------------- ' Contractor's Name-------- ---- ---------------------------------------------------------------------------------------------------- Phone.-:------------------------------ Installation will serve: Reside nc9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:7--- Number of bedrooms -1----- Number-of baths ./.......Lot size ------- ------__________________ Water Supply: Public system vCommunity system ❑ Private ❑ Depth to Water Table _ __-- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) i Septic T k: Distance from nearest well-----------------Distance from foundation------------__---_.Material_---.-_-_..___..._------._-_----__._-_-_-__-_-. No, of compartments------ ________ Size---------------------------------Liquid depth ------------. -Capacity -Dispos I Field Distance from nearest e!f__S0____._Distance from foundation----��------Distance to nearest lotne---V.___---- Number of lines---------- Eor_1__ff_--_ -- Length of each line-----3D_'------- ---Width of frenchz---- of filter material�-A-_&Q kDepth of filter material---._ -_---------Total length-----_-�'r-- _770_.---- Seepage Pit: Distance to nearest well _-__-_--------------Distance from foundation---------------------Distance to nearest lot line---_---.r--------. ❑ Number of pits-------- Lining material-----------------------Size: Diameter------------------------Depth------------------------------------ Cesspool: __-___-_-._.__--_----_ .a\` Cesspool: -Distance from nearest well-----------------Distance from foundation--------------------Lining material--.---_._--.--.------------._______- �I ❑ Size: Diameter------ `----------------------------Depth--------------------- ----- -------- °-- --------Liquid Capacity----------------------------gals. Privy: Distance�,romYnearest well_____________________ _Distance from nearest buiidin ' ' ❑ Distance to nearest lot line----------------------------------------------------------------------- Rem deli g an,/or repairing.{de tribe • -- ------------ --------- ---- G ------------------------ -- w..- ------------ I hereby certify thatlf have prepared this application and thatthe work will be done in accordance with San Joaquin County _ ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. \ igned}------ r-l` ------ -c ' --- an d/or ontract or)------ ( wner By:--------------------------------------------------------- ------------ = (Ti+le) ----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------------------------------------- ---------------------------------------- DATE.---------------------------- ----------------------- REVIEWED BY--------------------------------------------- --r--\- A-/. --------------------- DATE---------------- r5 BUILDING PERMIT ISSUED____________________________ _ __ -------------------------------------------- DATE Altera ons a /or recommendations:------------ -------- __.-. ----�/_ _ - = ll � 4-; .i: ----- _ -_:�: ---------- �: ..._� ___ _ ______________ -------------- ------------------------------------ -- - ------------------------------------------ --------- _ _ _ _ ----_--_-------_-___ ----- 46401-4 ---------------------------------------- --------------------------------------------------------- --- --------------- .1 --------------------------------------------------------------------- FINAL INSPECTION BY:- - 1 -- -- --------- ! .. - - Date------- SAN ��•�° JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revises 1-57 F.P.CO.