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APPLICATION FOR SANITATION PERMIT Permit No- ___- --T__.__ (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct ana work herein described. This application is made in compliance with County Ordinance No. 549.JOB ADDRESS AND LOCATION----- '-----7_---- / 2' ---- -`---`�"--- — - Owner's Name= = . �� � Phone --------------------------------- Address------------------f°/ � ---- --------------------------------------------- ------------------------------------------------------------------------------_ .... s 9 e-19 ----- - Y Contractor's Name-------f - � ------ Phone----9----------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms _2-_ Number of baths __i_____ Lot size ________________________-______________-__________________ Water Supply: Public system ❑ Community system '❑ Private N Depth to Water Table -------- ft. Character-of soil to a depth of 3 feet: Sand ❑ Gravel ❑. Sandy Loam N . Clay Loam ❑ Clay ❑ Adobe❑ Hardpan❑� Previous Application Made: Yes ❑ No fq New Construction: 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_____________-_-_______________--________-___. i ❑ No. of compartments--------------------------Size--------------------------------Liquid depth,------------------------Capacity----------------------- . r -�_a____---_.Distance from foundation___' = --____Distance to nearest lot line__ _ ________ Disposal Field: Distance from nearest well__ Number of lines-----------------------------------Length of each line--------------- -------Width of trench_-- --------------------- Type of filter ------Depth of filter material__----------------Total length________ 0•------------------------- 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-_--_______-_________________-_______ ❑ Size: Diameter--------------------------------------Depth------------------------------------------------ ---Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------- Distance from nearest building----------------------------------------- I ❑ Distance to nearest lot line-------------------_ Remodeling and/or repairing (describe):--------------------------------- ------------------------------------------------------------------------------------------ -----------------------------•-------------------•---------------•-------------------------------------------------------------------------------- -- ------------------- - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. -_ _ - (Owner-and/or-Contractor) (Signed) - � -,. - ---�--- -- -------------- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------- ------ ------------ ---- -------------- -- --------------------------------------- ATE ------C REVIEWEDBY--------------------------------------- ---------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------- Alterations and/or recommendations:---------- ---------------------------------------------------------------------------------------------------------------•---•----------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------------- ---------------------- ---------------------------------- -- ---- -------- - ---------------- ----- ---- FINAL INSPECTION BY---- --------------------------------------- Date / of ----------------- 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 8-51 Revised W-2100