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APPLICATION FOR SANITATION PERMIT Permit (Complete in in Duplicate) / S Date Issued .____14!1__ 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 compliancJI County kOinanc6 Na. 549. JOBADDRESS A LAT _ - ------------------------- - --------------------------------- -------------------------------------- Owner's Name----- -• --'- --------- -- -- •----------------------------------------------------------------------------------------------- ---- Phone------------------- Address---------�•----0- ------ - --- ----- - ---------------------------- ``=/ Contractor's Name---- ------- ---------------------•----------------------------------------------------------------------------------------------- Phone---------------------------------• Y Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths -------- Lot size Water SuPP! • Publics stem ❑ 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 ❑ O 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 death-=------------------------Capacity---------------------- Field: Distance from nearest well_________________Distance from foundation___---Distance to nearest lot line-VW-t —-___ } ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------------------- .Type of filter material-------------------------Depth of filter material---------------------.--Total lengfk------------------------------------------ Seepage Pit: Distance fo nearest well----------------------Distance from foundation_.-.-.__.......Distance to nearest ]of line----------------- R Number of pits----------------------LinincLrgaterial-----------------------Size: Dia/meter-----_----------------.Depth - ---- --.------------ -- ---- Cesspoo;- Distance from neare well __r7 !_ Distance fro fo dation__--!'-0_____---Lining material____ !�� --- -- - ------------- Size: Diameter------- �T--------------Depth---------- ! - ---------------------Liquid Capacity gals. Privy: Distance from nearest well---------------------------------------------- _-Distance from nearest building-------------------- -______________._____- ❑ Distance to nearest lot line---------------------------------------------------------------------------- Re oriel g and/or repairing (des ibe : - - ---- -- -�, --------------------------------....... ----------------------------- ... ---------------------------------------T---- -------------••--------------•------------- --------------------------------------- I hereby certify that I have prepar this application and that the work will be done in accordance with San Joaquin County ordinances, S e a , and rules and egul i s of the San Joaquin Local Health District. (Signed) _______________________(Owner and/or Confractory- By:-------------------------- ------------------------------------------------------------------------(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 - Alf erati s and/ r recorruherdations------------ n ` �----== "-------------------- ------- ---------------------- S - - ------ - --- �-e�.� ----------------------------------------- ----- E ---------- ------------------------------------- D FINAL INSPECTION BY:______- ___ :yp -7 J � J y ---------------------------------- ate---------- 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