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_ APPLICATION FOR SANITATION PERMIT Permit No_ ___ (Complete in Duplicate) Date 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 and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION---------------------------------------------------------------------------------------•--------------------------------------------------------------------------- Owner's Name---------- ---------------------------------------------------------------------------------------------- - ------------------------------------------- Phone----------------------------------- Address--------------------------------------------------------------------------------------------------------------•----------------1------- ------------------------------------------------------------------ Contractor's Name------------------••------------------------------•-------------------------------------------------------------------••----------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---- Number of bedrooms -------- Number of baths -------- Lot size _________________________________________-________.______ 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 ❑ 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 well-----------------Distance from foundation--------------------Material--------_`-_--_-__________._______.____.._______- ❑ No. of compartments--------------------------Size--=-••--------------------------Liquid depth------------------------- ----------- Capacity----------------------- - Disposal Field: Distance from nearest well_________________Distance from .foundation--------------------Distance to nearest lot line_________________- ❑ Number of lines----------------- -------------Length of each line.,=:-------- ---__r--'----Width of trench---------------------.------------- Type of filter material-------------------------Depth of filter material-----------------------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 material-------___.._---_-_._________________. Privy: Distance from nearest well----- De th` __ 'r_D - r -- Liquid Capacity----------------------------gals. ❑ prs ,e� '� stance from nearest building__________________________________________ ❑ Distance to nearest lot line----------------------------------------- ---------------•-•---------------------------------------------------------------------------- Remodeling and/or repairing (describe):-------------- ----------------------- j -------------------------------------------------------- - ---------------------------------=-----------------------------------------------------------------------•-- ---------------------------------------------------------------------- ---------------- ---------------- '; i.. ; ---------------------------------------------------------------- -------- ----- -- -- --_ - _----------------------- ---------- - j -------------------------------------------------------------------------------------- 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 rules and regulations of the San Joaquin Local Health District. (5igned)---- .- )-------------____(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). I FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-i............................ ------ ---=---------- ='---- -----------:--�ATE------------------------------------------------------------ REVIEW! D BY = - DATE---------------------------------------------•-------------- ' BUILDING PERMIT ISSUED-- - ------ ------------ DATE --------• -------------- -------- Alterations and/or recommendations-----------•------------ ---- -----z' ------- /-------.----------------- = '�"'�' - v------- ---- -- ------------------------------------------------------ --------------•------------ - - - ..a. --------- =----� "°� -------------..._... � . m i )------ ---------------------------------------------- ------------------------- ------ ------------------------- - -- ---------------------------- -- -------------------------------------- -------- ------ ------------- - FINALINSPECTION BY-------------------------------------------------------------- t Date---------------------------------- ----- --- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT - --- 130 South American Sfinef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M Revised 0.'59 F.P.Co.