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APPLICATION FOR SANITATION PERMIT Permit No. ... I�T � (Complete in Duplicate) (/ Date Issued .... 1 A lication is hereby fiiade to the San Joaquin Local Health District for permit to co ruct nd ' sta t work herein described. PP Y q P This application is made in compliance with County Ordinanc No. 549. �� JOB ADDRESS AND AT N_.. IOQ -/�� .- �1�ff- ---- �Www-I----- � ''7r Owner's Name-----Sl Y/ - Phone AddressJ'U-- ---- --------------•---------------------------------------------------•-••------- •---•----•••--------- ... _ Contractor's Name IPS` ---- ... Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑:. Other ❑ Number of living units: -f--- Number of bedrooms � __>Number of baths -Lot size ...' Water Supply: Public system E] Community system E] Private �epth to Water Table , . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe.-ardpan❑ Previous Application Made: Yes ❑ No New Construction: Yes n-17o ❑ FHA/VA: Yes e— lqo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet) Septic Tank: Distance from nearest well----7d---.__Distance from foundation___ _--M ------ eria4 - __.-. No. of compartments__-_ _.`_Size..i > ______Liquid depth____ ___ ____ __._______Capacity __ ; Disposal Field: Distance from nearest well---7� __Distance from foundation /Q.•___....Distance to nearestt"Jin ZK� Number of lines________02-________________ Length of each line_____- ..-___•-___.Width of trench ' Type of filter material/�f Depth of filter material---/ - -. Total length-----f � Seepac reit: Distance to nearest��yywell_.lee �om fou ation_.3Q--____----Dista�r ce to nearest lot linea'S [ Number of pits_.___vv Lining materiaV. Size: Diameter---•79--- Depth Cesspool: Distance from nearest well-----------------Distance from foundation _.._______-_--Lining material- - - ❑ Size: Diameter---------------------_--------------Depth------- --- -- ------ - - ---------Liquid Capacity ---•---• .-------•r•--gals. Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest building--------__._.-------------.___-----_--: 1 ❑ Distance to nearest lot line -------- ----- Remodeling and/or repairing (describe)-- ------ vda -- ,• 4_ __ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------•------------•------=------------------------•-----------•-----------------------------•------------------=-•-------••--•------------------------•---------------•-••---.•-. --------------------------- - ---•---------•-•------------------------------------••--------•-------------------•-----•--•-----•---•------------------•------------------------•--------------•-------------- I hereby certify that I have prepared this 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. (S(Signed) IJP i9 )------------------`--=i�� -'------A - - ---=�rte -�.�� -----,i-- -----------------------(Given 'Contractor) By:------------ lrtle � (Plot plan, showing size of lot, location of tem in relation to wells, buildings, etc., can be placed on rev a side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ -. --- - DATE ' • -----�-- ----- --------- REVIEWEDBY-------------------------------------------- --------------------------------------------------------------------------------- DATE------------•----_--_-------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-----------------------------------------------............. Alterattions and/or recommendations: ----- - .- .,Q -------------------------------------------------- '6 tel-. J�--- ICJ-�,.ic.�Dc,..v.[�'- ;�%`}� � s ---•-•-------•-----------------•-•----------------------•--•--•----•--------•-•----------------•---•---------------------•----------•------•------•----•--------------•---------•------•--_-------------------•--------- �. ------- ------- ----- ---- ------------ --------------•-------------- ---------- ------ -- FINAL INSPECTION BY --------- - ---------------------- ----- --- --. _ 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 , Revised 1.57 F.P.CO.