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APPLICATION FOR SANITATION PERMIT Permit No, (Complete in Duplicate) ► /�S jp 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, F JOB ADDRESS AND LOCATION----------------�---Z ------ Aj = Owner's Name---------------------J- --------- ------ ---- -- Phone Address------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------•--------------'=-- Contractor's Name---- -------------------- -=-----------------------------------------------------•---••- ------------•--- Phone----------------------------------_ Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms -___'_. Number of baths _-1___ Lot size ----- ------ _____..--__ Water Supply: Public system ❑ Community system ❑ Private'® , Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ Clay Loam E] Clay [-IAdobe [g—Htrdpan F]Previous Application .Made: Yes No ❑ New Construction: Yes No ❑ f 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 __40-----Distance from foundption___._ Material------ _ ap�a�city____No. of compartments--------- Size-_� _� _ _____Liquid de th__.___. -- ---------- Disposal Field: Distance from nearest well--•� Distance from foundation____Jb_..._..Distance to nearest lot line_--. Number of lines____________ Length of each line__-_______�+___A__.___._.Width of treneh---_---------fir--�.._------- r Type or filter materiaL_I__g__ -- -Depth offilter material--'-- - ----------Total length-------- _________-_----__--._ Seepage Pit: Distance to nearest well------_---------------Distance from foundation___________________Distance to nearest lot line_________._______ ❑ Number of pits----------------------Lining material--•--------------------Sizer•Diameter---- ------Depth-----.-------------------- --- Cesspool: Distance from nearest well----------------- from foundation___._-. _.______--Lining material---------------.. ._------__._____- W -- Size: Diameter----------------------------------------Depth-----------------------------------------------------Liuid Capacity- __gals. Privy: I Distance from nearest well--------------------- from nearest building-_---_..________________-____-_.__..._. ❑ Distance to nearest lot line----------------------------------------------------------------------"------------------------------- --------------------------------------- Remodeling and/or repairing (describe):------- ------------------------------------ ----------------------------------------- -------------------------------- ----------------------- f --------------------------------•---------•-----------•-------------•--------------•-----------------=-•------•-------------------•------------------------------------------------------------------•-----------" ---------- -------- --------------••----------------------------------- ------------------------------------------ •--------•---------••--•------------------------------------ •----•- -------------•------------------------------------------------------------------- --------- 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) - -_ "a____.---.-------- {-------------------Owner and/or Contractor By:------------------------------------------------------------------------------------ ------------------------(Title)----------------------------------------------- --------------- (Plot --------------------- - (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:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- -- -------- --------------------------------------------------------------------------------------•--------------------...------------------------. --------------•-----------------------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 io-52 Revised W-2100 G