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APPLICATION FOR SANITATION PERMIT Pbrmit No. . (Complete in Duplicate) Date Issued --- Application _-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. A JOB ADDRESS AND LOC ON----------- ------ ----- -- � Owner's Name ------- ---•--.----- ---------- ---- ---------------------------------- Phone----------------------- -- Address-------------------------------------------------•------.... Contractor's Name------------------- ------ --------- - ------ ------ -------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residencepartmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ - Number of living units: _/__ Number of bedrooms---_- Number of baths I____ Lot size __��/ �-------I_____________ Water Supply: Public system ❑ Community system '❑ Private epth to Water Table ________ ft. Character of soil to a depth of 3 feet:. Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Kg--Ha-rdpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes�o ❑ TYPE OF'INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic*-T-ank: , Distance from nearest weft_________________ Lane rte€ omfoundation___,_______ =Material ,_-=n-ti_ _______-___________----,---- _ ' No: of compartments_= _----Size------ - ----------------Liquid depth--- ---------------Capacity-----------•--•------ Disposa# Field: Distance from nearest weiL_____0 i*ance from foundatiioon____��_____ _. istance to nearest lot line___'(4__ Number of lines_____________ `_ -- ___Length of each line_,�r_�1_�' Width of trench_______-��r� jv�___ _ _____ Type of filter mate ria L�,_�__�'�..Depth of filter material______ �_ ____-_Total length________ _ �____ _______ Seepage Pit: Distance to nearest weft----------------------Distance from foundation--------------------Distance to nearest lot lin e_______________-_ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth---_----------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity--------- ------_--------gals. Privy: Distance from nearest well--------------------------------____________-_Distance from ne�eresi� building-_____._:___________________---------___- ; ❑ Distance to nearest lot line- ----------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------- --------------------•------------------------------------------------------------------------------------------------------------------------------------------------- ------ d ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------- 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 fhe San Joaquin Local Health District. I (Signed)__ --- ----- ------------------------ -------------------------------------------------------------------------------(Owner and/or Contractor) ------- f B __--------------------------------------------------------------------------------------------------------------------------------- i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 'FOR-DEPARTMENT-USE-ONL-Y ..,�.� . .,• ., APPLICATION ACCEPTED BY---------------- -------- --------:-------------------------------------------- DATE-------- - REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE ' BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterationsand/or recommendations:--•------- ------ -------------------------------------------------------------------------------------------------------•------------•-------- ---------------------------------------------------------- ------ -------------------------------------------------------------------------------------------------------•-------------------------••-------------------- ----------------=------•------------------------------- ---------------------------------------------------------------------------------- --------------------------------------------------------------------------------- --•---------------------------------------------------------------------------------------------------- �•-- _. FINAL INSPECTION B`"% >,�< 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 E5-9-2M 8-51 Revised W-2100