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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �/ � Date Issued ____/_ Appliea{ion 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. --II JOB ADDRESS AND tCATION _____I ---•----•----------�-------r...- ----.-�.-�`t_-�-� - . �_ ------------------------- ss ---------------------------- --•--------•----•--------- Owner's Name ------------ ---------------------------- ------------------------------------ ----------- Phone------------------------------------ ------------ ----------------------------•--- --------------------_- Contractor's Name_-------------- 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 system """"""`--"------"""------------- ppy' y ❑ 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 ElHardpan E]Previous Application Made: Yes ❑ No El New Construction: Yes E] No E] C. 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 depth-------------------------- -------- Type Disposal Field: Distance from nearest well_ -Distance from foundation__-_______.__-__._.Distance to nearest lot line_-_____. ___.___ ❑ Number of fines-----------------------------------Length of each line------------------------------ Type of filter material------------------------- W�dth of trench __ _ - -------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_----_-__ ' Cesspool: Distance from nearest well-----------------Distance from foundation---._____.._--___---Lining material____.___________________-" `' ❑ Size: Diameter----------------- V ---------- ept .....................Liquid Capacity als. Ilk Privy: /' Distance from nearest well-____---__--_-__50 ---------Distance from nearest building w Distance to nearest lot line---------------�-Q g -- -----------------. -- ---------------------- -------------- ---------------------- Remodeling and/or repairing (describe):--- -- --------- ------- -------- ---------------•----•----•----------------------- --------------------- ---------•---------•---------•-----------------------------------------------------•--------------•---------•-------•-------------------•---------------------------------- •---------------------------- ----- 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)-- Z -;, f a.K - -------------------------------------------- - -------- ------------------------(Owner and/or Contractor) -----------------------------••----•------------ Title (Plot plan, showing size of lot, location of system io wells, buildings, etc., can be placed on reverse side). --------=------- ----------- i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_______ DATE---- - ------ _ -- ----------------------------- - -- ---- ----------------------------------------------------------------------- DATE------ --�-�-- BUILDING PERMIT ISSUED----------------------- - ----- ----------------- DATE Alterations and/or recommend ations:_______.___"_________________________ %,� " :: ------ --------------------- -------------------------------------------- ------------------------ FINAL- INSPECTION BY:------ ------- ....... Date-------- ---•----- -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 NorfN,-"C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M ' Revised W-2100 ,,4