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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date 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 rdinance No. 549. j N ------ Owner's ADDRESS AND LOC ION--- ------------------------------"-- ---- ---------------------- --- - Owner's Name. .. -•- -----1-- Phone-------------------------- --------------------------- - --------- Address... - � ' f- -- -�'-- - Contractor's Name--.--•-------------• 'M-- -- ------------------------------ ----------------- Phone----------------------------------- Installation will serve- Residence IV, artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --1---- Number of bedrooms Number of baths ---0- Lot size --- ----- ---------------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan ❑ Previous Application Made: Yes ❑ No,K New Construction: YesA No ❑ 44C,1C {� 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 com Partments_-.-------_-______- Size-------------------------- - - - Liquid depth---------- ----- --------Capacity----------------------- rr Disposal Field: Distance from nearest wel)--,m5- -.-Distance from foundation----- --_.-.-Distance to nearest lot li e-- Number of lines-------- ---------- - Length of each line-------- - ,f. Width of trench.---r..Y- -- ------------------- Type of filter material-_- - Depth of filter material--------- - -----Total {ength_--.--- �� .-------_--..-_--------. Seepage Pit: Distance to nearest well-.a�.----Distance from foundation--- ----.Distance to nearest lot line ❑ Number of pits-------V----------- material----------------------.Size: Diameter------------------.----Depth _-------__-------------. Cesspool: Distance from nearest well-----------------Distance from foundation--------.-----------Lining material------------------------------------ ❑ Size: Diameter Depth - Liquid Capacity:_ .:gals. C s Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_:,___._.___________---_-----_____--._.__ 1 ❑ Distance to nearest lotline------------------------------------------------------------------------------------ -------------------------------------------------------- �1 Remodelin and/or re airin describe = M TM ------------------------------------------------------------------------- + ---------------------------------------------1 -S: ..-------a-------------_. _-- -O _ -_ --- ---------------------------------------- C -_ -+� .._-..-.--------------.-----_------._--__----------------_-__-- ----------------------•------------- V---_--_----------•------••--------_-_---_----____-_-_---_-_-_..-..__-___•___---------_----.-------_._---------_-_•__ .--. ...------------..- -________ 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. (Signed) (Owner and/or Contractor) By:------------------------------------------------------------------------------------- ---------------------------------------------(Title)-------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY - I APPLICATION ACCEPTED BY-------------------------------- ------------------------ --------------------------------------- DATE-----------...: ------------------ REVIEWEDBY----------------------------------------- - - ------------------------ -- --- - _ DATE ---------------- BUILDINGPERMIT ISSUED---------------------------------- -- --- -•- --- ----------------------------------------------- DATE-.-.---- ----- Alterationsand/or recommendations------------------- ----- ------- ----------------------------------------------------------------------••---•-----•--------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------•--------------------------- ----------------------------------------------------------------------------------------------------------------•---•--------------------------------------- -------------------------------------------------------•------------•------------------------------------ ------------------------------- -------------I----------------- ------------------------- - 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 10-52 Revised W-2100