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I 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. This1. tion is made.in tom liance with County Ordinance No. 549. � 5_ (pv—G JOB ADDRESS AND �JLO�C_ATION Owner's Name l a Phone ------------- - -------- ---------------- ---------------------------------- - --1.2. � / �� 1 - Address ---•----------------- ---- Contractor's Name---------- ------- --------------•--•------------------------------------------- ---------------------------------------------------- Phone----------------------------------- Installation will serve: Resident ❑ Apartment House ❑ Commercial Trailpr Court Motel ❑ Other ❑ cb/�--- Number of living units: _�ftumber of bedrooms _""~Number of ___. _______________________________._____________ G Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table P- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay E] Ado e E] Hardpan ❑ Previous Application Made: Yes E] R No New Construction. -Yes .N ❑ FHA/VA:,Yes E] No TYPCOF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 #eet.) �,eptic �ank: _. Distance from nearest well_________________Distance from foundation--------------------Material--------------------------------.__.__________- No. of compartments---------------�-------Size--------------------------------Liquid depth-------------------------Capacity----------r---;�--- Dis o I elcl: Distance from nearest well____-!.O__#Distance from foundati n.__i6-_----_-_-_.Distance to nearest lot line__1_Z________ ti e Number of lines----___I______ Length of each line_____ ., _ _i VWidth of.trench. '-- Type of filter material_____ ._ p g e th of filter matErial_________ _�S_ .__Total len th________._ _ _______________ v , N Seepage Pit: Distance to nearest well---------------------- 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 ----------------------------------- Remodeling ------Remodeling and/or repairing (describe)--------------.-------- ---------------------------------------------------------------------------------------------------------••------------------------ --------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- 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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- --------------------- --------------------------------------------- ----- DATE---------------------- -------- ------ ---------------- REVIEWEDBY--------------------------------------------------------- DATE-------��--' 0------ ---- ------------------- BUILDING PERMIT ISSUED------------------------------------------ —-------------------------------------- DATE--------------------------------------- ------------ Alterations and/or recommendations------------------------- ---------------------------------------------------------------------------------------------------•---------------------------------- ---- ..--- ------ 1 FINAL INSPECTION BY---------------- ----------------------------------------- Date ------------� --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Sfockfon, California Lodi, California Manteca, California Tracy, California 1 a ES-4-2M , Revises 1-57 F.P.CO.