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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. { JOBADDRESS AND LOCATION_-------- ---------- ------------------------------------------------------------------------------------ Owner's Name------------- -_ --------- Phone---------------- -- ---------- Address-----------------------------•--------------------------------------------•----------------------------------------- --------- - ----- -------------- Contractors Name----------------------- - ------------------------------------------------------ Phone----------------------- � 4 Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/---- Number of bedrooms - Number of baths _-_ __ Lot size -------S.f'.l ---- --- Water Supply: Public systemommunity system ❑ Private ❑ Depth to Water Table -------- ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9j—Hardpan ❑ Previous Application Made: Yes ❑ No ew Construction:' Yes4l . , -o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest welE -�—Distance from foundation-__- --.Material__-- . -` �-p- _ No. of compartments------ --_--Size--�•�-�� _�----Liquid dept----- --- ---------Capacity---- ---�_---, Pop. Disposal Field: Distance from nearest weld _ - v_dOistance from foundati�_--_ ______�DRistance to nearest lot line----- Disposal --- � Number of lines------------- - ---- --- Len th of each line- _�_'lt �/4A idth of trench-----___---, �� . - g Type of filter material__'.- -- depth of filter rnaierial----- -------Total length______- _ --- a---- Wi Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot li -__---__-----_--_ ❑ Number of pits-: Lining material-----------------------Size: Diameter------------------------Dept h--------------------------------- ` Cesspool: Distance from nearest we]-----------------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):------------------------- ----------------------------------- ---------------------------------------------•-----------------------: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ordinances State laws, and rules and regulations li the S�} d--ha h w will -- - -- in ----co -- - --- an --- _ _ _______ ___ ________________________'_.---__ y y prepared pp and-that the work will be done in accordance with San Joaquin County I hereby certif that I have re ared this application a n Joaquin Local Health District. l -. ------------------(Owner and/or Contractor) (Signed}_ -- -•--- ----- --- -- -- ------------ ---------------- ------------- By:__...-•----------------•-----------------------------------��---------------------------------------:---------------------- (Title} x (.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 <,---------------------------------------6!tarations and/6r recommendations:---------- ------------- __-.�__� ,_ _--� -- - - - ---- E -- / Xf r - ------ -- �. r..� FINAL INSPECTION BY:------------- f ate 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 B-51 Revised W-2100 t