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APPLICATION FOR SANITATION PERMIT Permit No. A090112 (Complete in Duplicate) - / ' bate Issued 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 OCATION-------- -/-0---- Owner's Name---------- - �. r Phone-------------------------------- Address---------------------- ------�� Contractor's Name------ '{ -tn.fl..--.f . =Gt +�-----e Phone ------------ Installation will serve: Residence IX Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑yOther ❑ Number of living units: ________ Number of bedrooms Z--- Number of baths _-/__ Lot size ________ __ _ ^-- r _______--------___ Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ 'Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ 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-----------------Distance from foundation--------------------Material__-------._-__________________---___________- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- .� Disposal Field: Distance from nearest well------------------Distance from foundation---------------------Distance to nearest lot line____________.._.. •yl ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------------------------ Type --------_---•---------------- ---Type of filter material______ _________________Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to neare well__S_, ��-----------Distance f o fours ation> _ ..... to nearest lot Number of pits - ------Lining materiaL�--Size: Diameter_____________Depth__--_- _ ,L'L Cesspool: Distance-from nearest well_________________Distance from foundation--------------------Lining material------------------------ -.-=5"•$izeYDiameter---------------------------------------De th-----------------------------------------------------Li uid Ca aci ---gals. Priv Distance from nearest well--------------------------------------- ____Distance from nearest buildin —"` ❑ Distance to nearest lot line------------------------------------------------ Remodeling and/or repairing (describe): LI ---- ------ --------------------------------------------------------------------------------- ----------------------- ---------------- - ------ -------- -------._..------------------ ------------------------------------------------------------------------------------4`- y� ------. -•----- ----------------------_.-------•--------------••--------------- { ;. -------------------------------------=-----•------------------------------------------- ---------------------------------------•---------------------------------------------------- ----------------=------------------ 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 fid r elation of the San Joaquin Local Health District. Signed( _ - U_--_ ( 9 )------ -----x----C�-- ------ - --� - - --�d�-.-'�-�.�.�✓..�---- ----�- -(Owner and/or Contractor) By:-------------------------------------------t---------------------------------- -----------------------------------------------------(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----------------------- --------- ------------------------------------------------------ DATE _- Alterations and/or recommendations------------------------ -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------__---------- ---------------------------------------------------------------------------------------------- --------------------------- FINAL INSPECTION BY:----� ✓- - - —------------ Date--------/�--+ -r------------------------ 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 8-51 Revised W-2100