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APPLICATION FOR SANITATION PERMIT Permit No. . .... . ........ (Complete in Duplicate) Date Issued f 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. ,, . JOB AbDRESS AND LOCATION ---------- = Owner's Name.--- -� ---- ----------- ------- ------------------ Phone s Address �r�s t ----------------- • -----------------------------------------.._..--------------------------•----- Contractor's Name--------d -------------------------------------- --------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other,�] #` Number of living units: -------- Number of bedrooms ________ Number of baths A.._. Lot size _ ------------------------ ont Water Supply: Public system ❑ Community system ❑ Private& Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamX) Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No W New Construction: Yes ® No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND`5PECIFICATiONS" ''"i' (No septic tank 6r'cesspool permitted if public sewer is available_ within 200 feet.) ' a lU..... Septic Tank: Distance from nearest well�_________:Distance fro foundation__ _ _ ____.Material___ __ ___ _-_____________________ No. of compartments:-A-__._.- - - tr Liquid de th.=___-41----_ Ca aci >��¢"�-_____ ------Size- ----------------------•---- - q P. - - - - �- P tY•-- 1„ Disposal Field; Distance from nearest.welLs1`::_ Distance-rfromzfo6ndatiorb n__- �__-____.Distance to nearest lot line__ _______. Q Number of lines__ _____ __._. Length of each line___?�'pp----------------Width of trench.•-rp�0----------------------- Type _____ _____________ Type of filter mater' - Depth of filter material--.A!-___--.---Total length__� ' �. Seepage Pit: Distance to nearest well.___._=�Distance,frorn 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----------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/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. ; [Owner and/or Contractor] (Signed) ------------------------------------------------------------------------- ------------------------------------------------------------ By:-----------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------------- -------------------- [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ - DATE"------ --------------------------------------- REVIEWEDBY--------------------------------------------------- -----------------=---------------•---------------------------------------- DATE------------------------------------------------------------- BUILDNGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:---_ --------------------------------- -4-- � - ¢ --- --- --•-•----------•--- dw ---------- 0 I -- ----------------=---- -------------------------------- ee -------------------------------- SAN ------------------- -- 1=1NAL INSPECTION BY: -_ ; 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--9-21A , Revised 1.57 FY.M.