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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) bate 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. A JOB ADpR S AIV - D LOCATI `� �-_ (�v�-�-_1- I — t t �� r �i, S Owner's Name. -------- ---- -- ------ Phone ---- ------ Address--------------� ----'-�-�-,�� -- � j <11 X ` � �� ContractorsName---------------4�------------------------------------------------------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel '❑ Other ❑ Number of living units: _______ Number of bedrooms ___1___ Number of baths ________ Lot size ___I______ ______________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam E] Clay Loam ❑ Clay E] Adobe ❑ Hardpan [ " Previous Application Made: Yes ❑ No New Construction: Yes 0 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----- from foundation-_- Distance to nearest lot lin Number of lines___________ _ �_----- Width of trench___ -__ --___- I _____________ Length of each line_________ ____ Type of filter material _--?_v_Depth of filter material______ _�j.__Total length___________________ __---------------- _111 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____-------_____________-_______________. ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------ = Remod ing and/or repairing escrib �_ - ________ �j-�_ - � ---a--__•_- -------------------- (-,-�-- --Pc 1 --------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ 3 ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- }. 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, d rules and regulations of the San Joaquin Local Health District. Si ned--- r GTi_z^ (Signed)- 9 ) r ---------------------------- - - - (Owner and/or Contractor) ---------------------------------------------------------------------------- ------ ------ Bl)• -------------r---------------- = = = `' ------------------------------------------(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------ ---�-� - �------ ----r- ------------- REVIEWEDBY---------------------------------------------------------------- --------------------------------------------------- DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------- ------------------ DATE------------------------------- Alterations and/or recommendations-------------------------------------------------- -------------------------------------------------------------------- s ----------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------ F ------------------------------------------------•-----------------------------------:---------------------------------------------------------------------------------------•------------------------------•----------•- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 4 -------•-------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ ----------------------------------- FINAL INSPECTION BY:---- Date--------- ------------------------- --- =----�---- ---SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street I Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100