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APPLICATION FOR SANITATION PERMIT Permit N . ....... ..------- (Complete in Duplicate) --� Date Issued ___�___-.__-�-��' Applica*ion 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---------- ------------F-------lf4i f_r l-�,�/ r------------------------------------ -------- Owner's Name------------------------------------------- _ -------- -11.----------------------- -------------------------------------- -- Phone------------------------------------ Address--------------------------------------------------------------------------1----------- --------------------------------------------------- Contractor's --------------------------•--------•-••---•------Contractor's Name__.------_--------------------------------------- � ---k"" "'I -----�� ----- - ----------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .........Number of bedrooms'______. Number of baths ________ Lot size __________________________________________________________- s 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 ❑ 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_...------ -----------`A Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line____._______.....rvJ ❑ Number of lines------------------------------- ---Length of each line------------------------------Width of trench-----------------------------------w Type of filter material_______ _______________Depth of filter material-----------------------Total length-------------------------------------- _-._\1 ti A�I / `l Seepage Pit: Distance to nearest well_- Q--------Dista 77�ce, from foundation----- -Q._____--.Distance to nearest lot line_______-___- Number of pits-___.__I___..-._.__Lining materi 111tt#d ___Size: Diameter____IYZ.�------Depth--------- r _ 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____..-_______-_______--_____.__._____._. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-------------- -------------------------------------------------•----------••------------------- -----------------------------------•-------------------- ------------------•------------------------------------------------------------•-•--------•-------------------------------•--•-------•-----•----------------•------------------------------------------------ --------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and ruless�and regulations of the San Joaquin Local Health District. Si ned --------------- -------- (Owner and/or Contractor) 9 ) ? _:_ B (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-----------........ ,•� REVIEWED BY--------------------------- ------------------------------------------------------- DATE ------------- - - -- -- - BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------•----------- DATE Alterations and/or recommendations:--------------- -----------------------------------------------------------------------••-----------•----------------------•-------------------------•--- r r - ---- ------------------------------------- --------------- - ------------------------------------------- -------- ---- -------------------------------------------------------------------------------------------------------------------------------------------------------------.._. FINAL INSPECTION BY----------- ----- -------------------------------------- Date------ - --------------------------•---- 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 /S-9-2M Revised W-2100 i