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�� FF10E USE: � ----------- ---------- - ------------------------------- APPLICATION •FSR SANITATION PERMIT Permit No. .- �r�� - ------------------------------------------------------ (Complete in Duplicate) Date Issued -r-'- v/� w --------------- --------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. Trois application is made in compliance with County rdinance No. 5 . 6 ---- JOB ADDRESS AND OCATION-- '19 �'" l s Owner's Name------------ ----- Phone- y: -------------- Address--------------------------- / Contractor's Name------- - --.___._•---------. Phone.. ��P-�•�� Installation will serve: Residence A artment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____ Number of bedrooms c-- Number of baths I/-- Lot size _._ Q__ �dQ-•---------------•-------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table �4 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application Made: (If yes,date---------- _---.___.) No ❑• New Construction: Yes ❑ No,W FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION LAND SPECIFICATIONS: ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4pjiTank: Distance from nearest well__._____-.____-.Distance from foundation____________________Material___.____..______--___:____.--_______-------____.No. of compartments------------------- ------Size_.--:---------------------------Liquid depth---------------- ----------Capacity...------.----------- eld: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot lin e_____________.-._ �" Number of lines-=-•------------------------------Length of each line-------•---------------------.Width of trench--------------.----------------- r V . Type offilter material-------------------------De th of filter material------------------ Total..length-------------------------------.------*_-_ 00 _ distance from f undation___ AO.......Distance to'neare5t lot line_ __- —------ Seepage Pit: Distance to nearest well___ /ky Number of pits_---I-------------Lining materia- -----Size: Diameter la-------Depth--- - ---------------------- Number of Distance from nearest well_________________Distance from foundation------------ material__.________.____-__.________-_______. ❑ Size: Diameter--------------------------------- --- Depth--------------------"------..----------------------Liquid Capacity----------------------------gals. Privy: :, Distance from nearest well--_--------------- ---------------------------Distance .from nearest building---._..____-_______--_______-.-__.__ - � ❑ 1 Distance to nearest lot line------------------------------------------------ -----_-------- •----------------------------------------------- ---------------- ----- ---------------h F ��.� " r Remodeling,and/or repairing (describe):_--- .. _._- '- ----------- -------- - - ----- ---- ------------------------------------- . / --- ---- --- - ---------- ---------- ---- -------------- -----------------• ----- -------- -----------------•--------------------------------------------------------------------------------------� -------------------------- ------- V I he e6ertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanceto laws, and rules and regulations of the San Joaquin Local Health District. --_____._ _ Owner and/or Contractor) (Signed)-- IBY: S ------ -- ---------------------------------------(Title) --- l (Plot plan, showing size of lot, location of system in #afion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ------ 5--------------------------------------- DATE-------- '{-z:--!x- REVIEWED 6Y ------------------------------------------ E ,-- --------------------- DATE ---------------=---- -- --- BUILDING PERMIT ISSUED__:-..:_ ' -_ '".._ .. ------_ DATE------------------------------------------------------------ ----------------------------------- ---- -------- o- Alterations and/or recommendation s:__._ N�� - T`� ------------------------------------------------------------------------------------•- --- -•------------------•- ----------------------------------------- t ----------------------------------------------------------------------- ---------------------- ---------------- ----�----------------------------- -�------------------------ -------------------------------------- ------------------= e z - ---------- ------------- -------------- FINAL INSPECTION BY:. :_ ----------- -- Date - �` SAN JOAQUIN LOCAL HEALTH DISTRICT 16o1 E.Huxellon Ave. 300 West Oak Street r 124 Sycamore Street *t 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California i ES 9 REVISED 8-59 3M 3-•63