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t ✓ � � r APPLICATION FOR SANITATION PERMIT Permit o r -� N . _ (Complete in Duplicate) Date Issued Applicatio 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 ANDOCATION_-__-_.--_/ --- -, -------- --- Owner's Name- -- ----------- -------- Phone- " "- Address f I-- ------------------------------------------ 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 -_-_s5�)/ d 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 E4<arclpan ❑ Previous Application Made: Yes ❑ No [?}'New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic TaI&I 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----------------------------- Width of trench Type of filter material-------------------------Depth of filter material----------------------Total length------------------------_ r� Seepage Distance to nearest ---Distaqnc r' m dation_ - - istance to neares# I line-__ t ��'`� ••---- Number of pits-------- ----------Lining materiDiameter_.__3 Depth-_.-- ._- ---------•--- Cesspool: Distance fiom nearest well_______________ Distaom .f..oun ation__.__-_.__._-______.Lining material__.__________- - --------------- --------- E-1 Size: Diameter------- ----------------------------- Depth-----------------------------------------------------Liquid Capacity- -------gals. Privy: Distance from nearest well-------------------------.-----------------------Distance from nearesr -buildin rr► ❑ Distance to nearest lot line--------------------------------------------- ------ ----------- 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, State laws, andel rules and regulations of the San Joaquin Local Health District. (Signed)-------- , . (Owner and/or Contractor) By:------- -----•--- -- --------------------------------------------------------- -------------------------------- ---------------------(Title)----- n (Plat plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- ------------------------------------------------ DATE-------�-- 7 _._- REVIIWED BY --------- - ------------------------------------------ DATE ------- BUILDING PERMIT ISSUED----------------------------------------- ---------•- ------------------------------------------------------------------ DATE-- -------------•---------- Aiterations and/or recommends+ions______________________. ._._ -----<-------•-------------------------•-------------•-------- ----------------------------------------------- ----------------------------------- FINAL INSPECTION BY:----- . . Date---- ------- . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street $14 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California ES-9-2M f0-52 Revised W-2100