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LMS APPLICATION FOR SANITATION PERMIT Permit No. .__ �.9�T. (Complete in Duplicate) Date Issuedo- a s^� Application 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______--------- C_ n------- Owner's Name_________ -----------------------------------------------�j - ---------------- ----- ---------------------------------------------- _____________ '9.2 fu G p � �3 - Phone_ ----4- --_--- ------------------------•--------------••-------------------------------------------•----------••-----.----- Contractor's Name_____________________`_ �� --- --------------------- �---------v - - -----------•--- Phone------------•-----•-----• --------- installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other Number of living units: -------- Number of bedrooms -------- Number of baths .____--_ Lot size ___________________________ ❑ Water Supply: Public system ----------"""""-""""------ - �-- Pp y� y ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay El Adobe E] Hardpan E]Previous Application Made: Yes�' No ❑ New Construction: YesNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 01 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----5- ---Distance from f unda ------- Material No. of compartments-,------r------------size-- ----.3- �.5 ,v� ---- - --- ---------•---Liquid depfih_-- ------�------ -Capacity----- ------ --------- Dispos IField: Distance from nearest well - ___. -_Distance from foundation_--_/0-�______-Distance #o nearest lot line________ Number of lines-------------- ---""-- ----------Length of each line_---------J (�l ` s!- ----- -------Width of trench.-----------Z �-�.--- --- Type of filter material_ --� r�'-----Depth of filter material--------.-,�`_r-_-Total length-----_-_--____ _ 5� Seepage Pit: Distance to nearest well-... "_ Distance from foundation-___-_-____-"-___-- Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material----------------------. ameer--------•------- Size: Diameter' -----------------------Depth--------------------------------- Cesspool: Distance from nearest well_______________ Distance from foundation ------------------- material_____ '1 ❑ Size: Diameter--------------------------------------Depth-------- ----------•-- - ----- ----- ------Liquid Capacity----------------------------gals. Privy: Distance from nearest yell_________ Distance from nearest building 4: El Distance to nearest lot -------------------4., Remodeling and/or repairing (describe:--------------------------------------------- ----------- ------------------- ----------------------------------------------------------------- ------------------------------------- -------•---------------•---------------------------------- ------ ! eby certify tha I have prepared this application and that the work will be done in accordance with San Joaquin County ordinan s, State law nd rules d regulations of the San Joaquin Local Heaith District. (Signed)-- -- - --- -----------------------(Owner and/or Contractor) By:-------------------- Title ------ ----------- (Plot plan, showing size lot, location of system in lation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------- _ _ r DATE REVIEWED BY ---------------------- ---------- ------�--- ---- -- - DATE [4. `Z-�4�--2-{---- ------- ----------------- -------- DATE------------------------------------$UILDING PERMIT ISSUED----------•---• -------------•- ------------------ ------------- -•-----------------------------------------------------------I-----.- Alterations and/or ecom_mendations---- ------------- -------- ---------- DATE ------------ ---------------- _ -3_/' -�._ ---- - ------ --------------- ----------------- ----------------- ---- ---- -- ---------- ------------ -------------------------------------------------------------------------- ------- 1/ �l --- ----------------- FINAL INSPECTION BY:-------v-----=fit- IIt j Date------ ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100