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- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Applica+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. JOB JDDRESS AND LOCATION------------------- ______ _ ____.____ - Owner's Name ------------ -------------- Phone------------------------------•---- Address---------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------------------I---------- Contractor's Name-------------------------------- ------ ------ ----------- ------------------ -------------------------------------------- Phone------------:--------------------.. Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --"____ Number of bedrooms ____ _ Number of baths __2rLot size ------ � ____________ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table ---------ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g3--Uardpan ❑ Previous Application Made: Yes ❑ No ew Construction: YesC--No•-❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) . Se PicTan Distance from nearest well________________Distance from foundation-------------------.Material____________._____.__---_--____---------..___-__. No. of compartments------ -- ---------------Size--------------------------------Liquid depth-------- - ---- -------- Capacity---------- Dispos I Field: Distance from nearest w II d -Distance from foundation___ _ ____ _..Distance to nearest lot line--- Length of lines ------- ,-_Len th of each line.___ Width of trench_._________. t } gf- _ �� Type of filter material-- -17 of filter material"_-"G ____.__Total length_____-----------&------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------._.___.Distance to nearest lot line______________... ❑ Number of pits----------------------Lining material-----------------.-----Size: Diameter-----------------------Depth--_------------------------------ . Cesspool: Distaice from nearest well-----------------Distance from foundation.-.------- -------- Lining material -..--_...____.____.______________ __. Size:-Diameter--------------------------------------Depth------------------------------------ -------------Liquid Capacity _. � --- -----gals. , Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ElDistance to nearest lot lire------------------- - ------------- -------- ------------------------- ---------------------------------------------------------------------- Remodeling and/or repairing (describe):----------------- - -------------------------------------••------------------------------------- --'-----"-"--------------------------------------------- --------------------------------------------------------------•-----------------------------------------------•----------•---------------------------------------------- ----------------------------------------------------- 7 ----------------------------------------------------------- ---- - y ------------------------------------------------------------ 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 rul and regulations of f e San Joaqu'rf+� _c althAistrict. [Signed}.... -=- ------ -----=--- -- -n_ -- {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------------- ------ ----�------ REVIEWED BY-------------------------------------------------------------------------- --------------------------------------------------- DATE--------------------- ----------------------------- BUiLDING PERMIT ISSUED------------------------------------------- ----------------------------------- ------ DATE--------------Y----------- -- ---------------------------- Alterations and/or recommendations:--------------- ------ -- ---------------------------------------------------------------------------•----------------------------- -------------------------------•------------------------------------------- ------------------------------ -----------------------------------------------------•---- ------------ -------------------------------"-"------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------•--- --------------------------------------------- ------- -----------"----- - ----------I ------- -------------------------------------------------------------------------------..-----------------------•------------------ FILIAL INSPECTION BY:------ -- ------ -- ------------------------------------ Date------- --- ----3.- ------ --. -------------------------------- 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 Revised W-2100