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_ APPLICATION FOR SANITATION PERMIT Permit No. _________ (Complete n 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 Ordinance No. 549. JOBADDRESS AND LOCATION------------------------------------- ----------!--------------••--------------------------------------------------------------------- •------•------------ Owner's Name---------------i----------------------------------------------------------------- ------------------------------------------------------------------- Phone----------------------------------.- Address----------------------- --------------------------------------------------------------------- Contractor's Name-------1 ------------------------------------------------------------------------------------------------------------------------------- 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 Isystem ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of'3 feet: Sand ❑ Gravel ❑ Sandy Loom ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATI N AND SPECIFICATIONS: (No septic tank 6r'cesspool permitted if public sewer is-available within 200 feet.) Septic Tank: Distance from nearest well---------- ------Distance from foundation--------------------Material____._.________.__-__------_--_:____._.__-_____. - t ❑ No. of compartments---------------- ---------Size-------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well_________________Distance from,foundation--------------------Distance to nearest lot line--------------. ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------_---------— ' Type of filter material_________________________Depth of filter material-----------------------Total length__________________________________.__-- Seepage Pit: Distance to nearest well------------- ________Distance from foundation--------------------Distance to nearest lot line--__--___-___--._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----.------------------Depth-------_---------------------.-_ Cesspool: Distance from nearest well------------------Distance from foundation.. ---------------- Lining material_-____._.-__-.____.________-------_ ❑ Size: Diameter------ -------=----------:------- --Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well ----------------- ------------ ------------------Distance from nearest building---------------_---___________-_____-____. ❑ Distance to nearest lot line________________________ -; �k Remodeling and repairing (describe)------------------------------------------- - ----------------------------------------------------------------------•-----------------------------------••----------------------------------------------------------------------- ---------------------------------- --- - ---------------------------------------------••----------------------------------•----- ----------- I hereby certify that I have prepared this application and that the work will be donGj in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health Distri t. (Signed)---------------------------------- ---------------------------------------------------------------------------------------.-------- ----- ------(Owner and/or Contractor) By--------------------------------------------------------------------------- ------- - -------- -------------------------------(Title)----------------------------------- •-------------------------- (Piot 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---------------------------------------- .r�---------------------------------------------------- DATE------------ REVIEWEDBY---------------------------------------- ---- -------------------------- ----------------------------------------------------- DATE-------------------------------------------------- BUILDING PERMIT ISSUED--------------------------- ------------------------------=------------------------------------------ DATE -- ------------------------------ Alterations and/or recommendations:___________________________________________________________ , -•----------------------------------------------------------------------------------------------- -----------------------------------------------------------•-------.-_---------------------------------------------------- -----------------------------------•-------------------•------------------------------------------------------------------------------------------ -------------------------------------------------- •---------------- ------------------------------------ • 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 Revisea 1.57 F.P.CO-