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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. This application is made in compliance with County Ordnance No. 549, JOB ADDRESS ANDLOCATION__________ ___ ---- ------ - --- ` Owner's Name ---------------- Phone------------------------------------ Address------------------------------------ ----------------------------------------------------------------------------------------------------------------------••-------------------------------------•------- Contractor's Name---------------------------- --- --------------------------------------------------------------------•------------- Phone----------------------------------- Installation will serve: Residence t Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ qter ❑ Number of living units: _1--- Number of bedrooms ___L___ Number of baths/------ Lot size ________ 7 �_- `. -------------------____ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet. Sand E] Gravel ❑ Sandy Loam E] Clay Loam E] Clay ❑ Adobe �'arcl ❑ Previous Application Made: Yes �o ❑ New Construction: Yes Ugoolldo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if 411c sewer is available within 200 feet.Septic Tank: Distance from nearest well-__ _____.__ _-_Distance from undation__--_�_ _._ . __.Materi I-_ ---� ,_______.__ No. of compartments__.___.-.__YY___Size �� Liquid ds . h___- ____.__Capacity..-__ Disposal Field: Distance from nearest ell_ , Distance from foundation----,l_D__.__ _. is ante to nearest lot line__ Number of lines"19 _____________ Length of each line------------- Width of trench_. ------ --------------- Type ___. / --- T e of filter material__ Depth of filter material___ rr________._Total length_____Sir_�'t_____ ___ _ ______ y p � � V$__ 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------------------------------------- ElSize: 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) 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---------------------------------------•----.--------------- BUILDINGPERMIT ISSUED--------------------------------------------- ---------------- -------------------------------------- DATE---------------- ----------------------•---------------- Alterationsand/or recommendations:------------ -------------------------------------•------------------•--------------------•-•---------------•-------•--••------------------•------------ ---------------------------•----------------------------------------------------------------------- --------------------------------- --------------------------- --------- --------•------------------ --------------------- ---------------------------------------------------------------------- ---------------------------------------------------------•--------------- -------------------- ---------------------------------------------------.-- ---------------------------------------------------------------------------------------------------------- ----•-•-------------------------------------------------------------------------- --------------------------------- FINAL INSPECTION BY:-------------lr--�C3---------------------- - --- -------- Date. --- I SAN JOAQUIN LOCAL HEALTH DISTRICT rr 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 ;0-52 Revised W-2140