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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 Ordinance No. 549. SCP �U JOB ADDRESS AND LOCATION. _ _ �-- --- --- ------------------- --f7_ .'- -------------------------- Owner's Name ----•------ ----------------------------------------- -- -------- Phone---- Address '�j ----------------•------------------------------------•-•----- ------ -----------••--- -----.......... ContractorsName------•---------- -----------------------------------------------------•------------------------ Phone----••---------------------------- Installation will serve: ResideI partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _-- Number of baths __I_____ Lot size ------- /- Water Supply: Public system ❑ Community system ❑ Private 4"I` Depth to Water Table f3__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe Hardpan ❑ Previous Application Made: Yes ❑ No K New Construction: Yes [X No ❑ FHA/VA: Yes ❑ NOX 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_ _6_6-!7:�Distance fromfoundation____ y ".-. -a- s ---- ---- ------ C-...�-'-'� No. of compartments-------7 ------------Size--- A . t -4- ___ --Liqui - y � -�N- ------ Disposal Field: Distance from nearest well__f -------Distance from foundation___) __.____Distance to nearest lot line__ __. Number of lines-------- /_-____ �! __--- Length of each line_______� ___ -------Width of trench.___ 1 11 Type of filter material-A----- _SDepth of filter material__,V,V------------Total length------- _ __- �_______-____ 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 materia!--------------.____________----_--__. ❑ Size: Diameter---------------------------•=---------Depth--------------------------------------- ------------Liquid Capacity----------------------------gals, l- Privy: Distance from nearest wel ___1____________________________________________Distance from nearest building__________--_-----___________-___-______ ❑ Distance to nearest lot (�line �----------------------------------------------------------------------- -------------------------------------------------------------------- Remodeling and/or repairin `_�___ ,� _j,�"� .rc --_ ,r¢ .c�. �.---------- --------- .r---- ------------------------------------- --------------------- ------------------------ ----------- -------•-•-------------------------------------------------------------------------------------------------------------------------------------------------------------- --- --------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------ 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 re`gullaations of the San Joaquin Local Health District. (Signed)----- " _ r -------�--------------------------------------------------(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- ----- - --------- BUILDING PERMIT ISSUED---------------------..._-------- -------- DATE-------------�-�-------� ------ Alterations and/or recommend ations---------=----- ' `— ---- --- ------ --------•-------------------------------------•------------------•---------------------------------------------- ---------------------------------------------------•----------------------- ----------------------- ----------------------------------------------------------------------•----------------------------------•--------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:------------------ -•-�/ - Date------------------- 1 ----------- ---�------- --------------------- SAN ------------------ 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 Revised 1.57 F.P.CO. 1