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APPLICATION FOR SANITATION PERMIT Permit No. . ..__ . ---- --------- Q (Complete in Duplicate) Z Date Issue 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 ADDRESS AND LOCATION---- . ---------- Owner's Name --------------------------------------- Phone : Address------ •---••- ---- --------- --••- . ... -•-- ---•------ ................................................... ............................................ Contractor's Name-------- ----------�.. . ... --------------------------------------- Phone.. '"..__ -:- - .. _. Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ otel Other E]Number of living units: -/-_-_ Number of bedrooms � Number of baths ../___ Lot size .. — ---_ - Q.. Water Supply: Public system Community system E] Private [-] Depth to Water Table• eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobAiEr'01-lardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑T INO J� TYPE OF INSTALLATION AND SPECC TIONS: F ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic Tank: Distance from nearest well_________________Distance from foundation..---.--------------Material_--__--_____---.-__---_--__-__-___---__.-_______- � l o. of compartments--------------------------Size---------------------------- Liquid depth--------------- ----------CaacitY oo1 Disposal Field: Distance from nearest well_________________Distance from foundation to nearest lot line-__-•--_-_______- y� �,r ► lumber of lines-----------------------------------Length of each line----------------.-------------Width of trench-------_--------------------------- JI� !1 (//Type of filter material-------------------------Depth of filter material-------------.---------Total length------------------------------------------ VJ Seepage Pit: Distance to nearest ell-P-T �___Distance f m f wn tion_ �._..�..Dis apce to nearest lot line___,ar__�__ M Number of pits-_-.. -__._____Lining material _ _- ize: Diameter.....,,' I p /� -- 1 esspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-._.-__-_.___---_-.___--__.-_.__--__. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity--------- -------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------.----------------------------- El _--- ___-_--___-.__-.____.-.❑ Distance to nearest lot line-- ------------ Remodeling and/or repairing (describe):---- - F-------------------------------------------------------- go; -------------------•----•-••-----------•--•-----...--•••---•--•--•--•---•---•------------•----•---•--------•---------------------------------------------•-----------------------------------------•------------------------- -------------------------------------------------------------•----•----------•--------------------------------------------------•----------------•-----•--------------------•------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State LOMN, and rul n egulations San Joaquin Local Health District. (Signed)------------------ --- -- -------- ---- - - -------- #---------------------------------------------- (Owner a o Contractor) By:•-•-•---••---•------•---•• a----------------------------------- --------------------------------(Title ------- - ---------- (Plot ----- -. (Plot plan, showing size ot, location system in relation to wells, buildings, etc., can beed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE ----------.. REVIEWEDBY------------------------------- --------- -------- ------------------------------------------------ ------ DATE------ BUILDING PERMIT ISSUED-----------------------------------------------------------------••-------------------------------- DATE--------------------------- Alterations and/or recommendations-------------------------- -----------------------------------------------------------------------------------•----------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- •----••----••------••-- -------------------------------------------------------- ------------------------------------ --------------------------------------------------------- --------------•------------------------------------------------------ -------------------•-•--------------------------------•------------------- ------------------------- FINAL INSPECTION BY:--------- -. �✓f! l!�':v'------- ------------ Date--------u - 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 I0-52 Revised W-2100