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FOR OFFICE USE: - ------------------------ ------------ ---------- A7. IV----------------- APPLICATION 4 FM SANITATION PERMIT Permit N,0_1��,_�& A--------- --------------------- - --------------- [Complete in Duplicate) ------------------- ----------- — - ---------- - This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the Son Joaquin Local.Health District for a permit to-construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB 1� sz ADDRESS AND LOCAT150 _0 — -- -------0'. . ---------------------------------------------------------------- -------- ------------- - 674 1 _. Owner's s Name-------- ep-_�__ ------------------ el -------------_-Phor)e----------------------------------- ----- -=-------------------- Address---------------------- A- Contractor's Name---------- ---------------------------------------------------------------- Installation will serve: Residence'[�Apartmerif House E] Commercial E] Trailer Court [] Motel [] Other ❑ `Number of living units: J---- Number of bedrooms ---?.__ Number of baths _1---- Lot .size ------ Wafer, Supply: Public system p Community system El Private E] Depth to Water Table 4 Character of soil to a depth of 3 feet: 4Sand Ej Gravel E] Sandy Loam E] Clay Loam El Clay [] Adobe E2" Hardpan 0 Previous Application Made: (If yes,date--- ---- ,..____._J No 2� New Construction: Yes E' ] No [P- FHA/VA: Yes 0 No [�J— TYPE OF INSTALLATION AND SPECIFICATIONS: i(No septic tank or cesspool permitted if public sewer is available wifhi; 200 feet.) 4 I Septic Tank: Distance from nearest well----------------Distance from foundation--------------------Material ----------------- No. of compartments-- ------- ------------Size-------------------- `---------Liquid depth------------ -----------Capacity----- t Disp,7aField: Distance from.,,nea rest Distance from foundation___l4____ Distance to nearest lot llne___Y� Number of iines-1 Length of each line-------6-0 of trench------7--y-------------------- Type ren I h------A--,/.......... --------- ---------- -------------Width Type of filter m;terial----- of filter material----"W ....... .Total length_____.__. e------------------------ Seepage Pit: Distance to nearest well---4�!?Ai_-e-------Distance from founclaflon___Z_!_'-----------Distance to nearest lot iine-5----------- P" Number of pits-."--/--------------Lining material__"- -k----Size: Diameter__..3Depth....;X_.--""""-"""- I -------- Cesspool: Distance from rear6st well-----------------Distance from foundation--------------- --Lining material_._.._."--.__._❑ Size: Dram -- ------------------------__..Depth--------------------------- -----------------:_Liquid Capacity--------------------- �naan-�, I ------- Privy: Distance from nearest well---------------------------------- --,-------.--------------D}�stance from nearest building__-------------------------- r Distance to nearest lot lire--------------•-------------.--.---------- - -------------------------------------- x Remodeling and/or repairing (descfi�"):_---------------------------- --- - --------I 61 ------ ---- ------------------------ ------------ ------------------- - ----------------------------- ----------------------------------------------------------------------------------------------------------------------- ----I-------------------------------------------------------I------ ---------------------------------------- ------------------------------------------------------ - ------------------------------------ ------------------ ----------------- ---------------- ------------------------------------- -------------------------- -------------------------------------------- -------------------------------------------- ----- ---------- --- - I hereby certify that I have pr6"Pared this application and that the work wili*bed� one in accordance with San Joaquin Couniy ordinances, State#1awsan rules and regulations oft n Joaquin Local Health District. (Signed)----------------- --- ---- --------- ----- i--------- -------------------------- --------------------(Owner and/or Contractor) By:. ------------- -------- -------------------------------------------- [Title}--------- -------------- ---------------------------------- -------- ------ ----------------------- (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 APPLICATION ACCEPTED BY-------- ------------------------------------------------------------------------ DATE------` —--------------------- REVIEWED BY --------------- --------------------------------------------- DATE---------------- BUILDING PERMIT ISSUED---------- ------I--------------------- ------------------ ----------- DATE-------------- --r---------- - ------------ ---------- -------- ------- Alterafij?ns and/or recommendations:------__--Y/2_ ----------- ------------------- ------------------------- ------- —---------I ---------- ------------------------------------ -------------------------------------------------------- ------------------- -----------1-----------------------------I-------------------- - ---------------- ---------------------------------------------------- ------------------------------- ------ ---------------------------- ..................... ------------ ------------------ ------------------------- --------------------------------------------- ------------------ ---------- -------------------- ------ ------- -------- ------------- ------------------ --- --- -- ----------------- -- -------------------------------------- ------------------------------------------------------------------------ t-------------------------- ------ FINAL7INSPECTION BY:..: -------------------------------------- ......... ---------- --- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maxelton Avo. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California I . Manteca,California Tracy,California F.P.Cn.