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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) , Date issued •____5 /,� Applica+ion is hereby made to the San 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 ADDRESS AND LOCATION.J1___J_9-03--------- Owner's -•-- Address.................. - -----•---•----------------Contractor's Name Name----- IPA ` ------------------------------------•------- --- ------ Phone-A4---6-y r 0-7--- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1-_- Number of bedrooms ____2—Number of baths ._ Lot size ----- _____ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _wd ft. i \Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam-E] Clay [] Adobe [3--ttardpan ❑ Previous Application Made: Yes ❑ No /Flew Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) w Septic Tank:' �n Distance from nearest well-----------------Distance from founda+ion________._________ Material__________-___.-_-__-___-_-___.____.______-___. ❑ S f No. of compartments------ ------------- ---Size--------------------------------Liquid depth----------------- --------Capacity-•--------- i $ h4{rGN-" p -- Disposal Field: Distance from nearest we�i- O-_-__._Distance from foundation_____- ___/-._Distance to nearest lot line----JJ Number of lines-=------------�_ - Len th of each line--------�f'-- -�-------Width of french-------- -fl !! --------- Type of filter material-__ - -S '-Depth of filter material____._-f --______-Total length_____-__-2_5--- _-_-----_ Seepage Pit: Distance to near e well----7✓�___-_____Distance f om foundation------ Q- -_-.Distl�ce to nearest [of life_- -_�---_ i -_-_--Lining � c ®� Number of pits-_'----_l-_-- material-- --��_C�.,,ize: Diame#er_-. _ ---.-----Depth. __�-J--------------- Cesspool: Distance from nearest well __-___---------Distance from foundation___________________ Lining material-_____-_____-_-_ Size: Diameter--------- ------------ ----------------Depth-------------------- -- - --------------Liquid Capacity----------------------------gals. Privy: Distance from nearest yrell---------------------------------- - - .----------Distance -from nearest building-____.--____.__-_- El Distance to nearest lot line_______-.._-____. --------------------------------------------------------------------------------------- Remodeling and/or repairing fdescribe):------..041 _44 -A06-1-_( J/ Z' - ----------------••----••-------•-•--•----------- ----------------------------------------------------- -•------I--------------------------------------------------- -----------------------------------------------------•-- •----•------- -------------•------------•---------•---------------------------------------- --- I hereby certify that I have prepared ibis application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------- I -! S t nC r Contractor) BY= (Title)---- p (Plof plan, showing.size of lot, locafion of system in relation to wells, buildings, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY--------------------- ---REV --_ -- -- -------- DATE--------. __.----------_-- -- -----_----------------- IEWED BY ------------- ---- -------- - ------ DATE---------------�----;;BUILDING PERMIT ISSUED DATE ----------------------------------- ------------------•--------- ------------ Alterations and/or recommendations:_-_________ `' = ----------•- a --------------- ------ 51------ -- --------------------- ---\_ ---------------_----------- - - ---••- -------------•- ------ -------------------------------------------------- ----- - - FINAL INSPECTION BY:-- •- --------------- ----- Date------ � - ---------------------- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 We't* Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, &Iifornia Manteca, California Tracy, California E5-9-2M 145446 A ,WpOo,//12-54'