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APPLICATION FOR SANITATION PERMIT Permit No. - (Complete in Duplicate) Date Issued 1 . 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. JOB ADDRESS AND LOCATIO ----------- --- ------------ ----- -- --- --- Phone- , =__ --- - -._Owner s ame----------------•----- Address Address----------------- --------------------------------------- -------------------------------- --------- ------ ------------•--•-----------•-------------------- 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 I-------Lot size -----/5--.0---- -----------• 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 ❑ i Previous Application Made: Yes E] No SE Construction: Yes No E] 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_..-------------------- Dils osal Fi 6Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_______________-. ❑ Number of lines-----------------------------------Length of each line-----------------------------Width of trench Type of filter material__-_ ___________------Depth of filter material-----------------------Total length---------------------------_--------__--•- Dis ante to nearest lot line _ Seepage Pit: Distance to nearest well---JVC't---_Distance fro foun ation_ �_ � M p Number of its---- - -----------Lining materia ----_-� --- ize: Diame e -- --Depth - � Cesspool. Distance from nearest well------_------____Distance from foundation-----------------._.Lining material-- ---------------------------- -____. ❑ Size; Diameter-----. Doth- ------ - -- -- - Liquid. Capacity_��--------=gals. A. Privy: Distance from nearest well_- Distance from nearest building------------------------------------------ Privy: ____ _______ _________________________ ❑ Distance to nearest lot line---------- ----------------------- --------------------------------------------------------------------------- 9 Remodeling and/or repairing (describe)_--------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ - ---------------- - - ------ - ------- ------ ------ ---- ---- - ----- --- ---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, tate laws, and rules and spgulajlons of the San Joaquin Local Health District! ts� (Signed)=---•------ ------------------------------------------------ 10.wrier and/or Contractor) -- --------------------------------------- Title --------------- ------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). x FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- - -------------------------- DATE �% "--------Z- REVIEWED BY-------------------------- ------ ---- - ------------------- - DATE------------------------------------------------------------ - - -------------- -- ----------------------------------------- - -- BUILDINGPERMIT ISSUED-------------------- ---------------------- DATE-------------------------------------------+----------------- Alterations and/or recommendations:--•------------------------------- ----------- -----------------------------------------------------•-----------•-----------------------------•------------- ------------------------------------------------ -------------------------- 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 i ES--9-2M 8-51 Revised W-2100