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APPLICATION FOR SANITATION PERMIT Permit No. ............. (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued _______________________ 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 ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms -------- Number of baths -------- Lot size _______________________-______________________________.__-_ Water Supply: Public system ❑ 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❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ 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--------------------------Capacity----------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line.-__---___-______ ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench-------------- of filter material----•--------------------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-------.---------------Depth--------------------------------- Cesspool: Distance from nearest well----------------_Distance from foundation------------_------ Lining material-------------------------------------- M Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity .------------------------gals. Privy: Distance from nearest well------------- _ -_---.-_-_-________----___._----- --Distance from nearest building----- ❑ Distance to nearest lot line------------------------------------ ------------------------------------------------------------------------------------------------------------- -_ 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) Sri--------------------------------- ------- -----(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 APPLICATIONACCEPTED BY-------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ REVIEWEDBY--------------------------------------------- --------------------------------- ---------------- - ---------------------- DATE-----------------------------------• • BUILDINGPERMIT ISSUED--------------------------------------------------------------—---------------------------•---------- DATE------------------------------------------------------------- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------•----------- -------•----------------------------------------------------------------- ----•--------------------------------------------------------------••------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------- --------- --------------- ------ - - - - ------------ ---------------------------------------------------------------------------------------------------------------------------------- --------------------------------- FINALINSPECTION BY:---------------------------------------------------------------- Date----------------------------------------- ------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT t30 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy. California ES-9 2M ReV}ed.8,59.E.P.CO. z„ :✓