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FOR OFFICE U5E; - "'-------'--------------------------- APPLICATION FOR SANITATION PERMIT Perm' " o. ........... --------------------------------------------------------- (Complete in Duplicate) ate Issued _______________________ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct an install the work herein described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION------------------------------------------- r------------------------------------------------ -------------------------------------------------------------------- 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 aths -------- Lot size ------------------------------------------------------------ Water Supply: Public system ❑ Community system ❑ Private ❑ epth to Water Table ------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel p Sandy oam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------I No ❑ ew 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 weft-----------------Dis ante from foundation--------------------Material--------------.------_-------.-------------_-__. Na.El of compartments---------- ------ --------Se--------------------------------Liquid de th------------------ - Ca pacify Disposal Field: Distance from nearest well istance from foundation--------------------Distance to nearest lot line----------------- El Number of Tines--------- -------------- --Length of each line----.------------------------.Width of french------------------------------------ Type of filter material---------- ----- --__Depth of filter material----------------------Total lengfh------------------------------------------ Seepage Pit: Distance to nearest well------------ _------Distance from foundation--__._.-----------.Distance to nearest lot line ---_- ❑ Number of pits----------------------L' ing material-----------------------Size: Diameter----------------------:Depth--------------------------------- Cesspool: Distance from nearest well- --------------Distance from foundation....................Lining material--.---....-.-..-------.-.--.-_.__-_--. ❑ Size: Diameter----..,.------ - ---------------Depth------------------------------ ---- - -------------Liquid Capacity----------------------------gals. Privy: Distance from nearest w I-------------------------------------------------Distance from nearest building.-..______._____---------_----.---------. ❑ Distance to nearest lot ine------ ----------- -- ----------------------------------------•--.------•----------------------------------------------•- Remodeling and/or repairing (describe ._ ---.----- ---- --------------------•---------------- ---------------•----------• ------------------------------ ---------------------------------------------I------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules a regulations of the San Joaquin Local Health District. (Signed)_-------------------------- --------------- --------------------;------------------------------- ------- ------- -------------------------- ----(Owner and/or Contractor) By:---------------------------------------------------- A------------=---------------- ------------------------------ ----(Title)--------------------------------------- --.. .- --- -------- (Plot plan, showing size of lot, to ation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -----_ ---r-- ---- ---------------------------------------- DATE---------------------------------------------------- ----- - - REVIEWEDBY------------------------ -------------------- ------------------------------------------------------------------------------- DATE = BUILDING PERMIT ISSUED---------------- ----------------------------------------------------=- DATE----------------------------------------------------------- Alterations and/or recomme dations:------------------- ------------ --------------------- ----- ---------------------- -----------------------------•------------- -----•----------- FINALINSPECTION BY-------------------------------------------------- --------- Date ------------------------------- ------------------------------ SAN ----------------------------SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California