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FOR OFFICE USE: ------------------------------------------------------ --------- ----------------- ....................... ----------------------------___--_.-_---------------."_.-"."__..._.......__-__._... APPLICATION MR SANITATION PERMIT Permit No. ........................ " --"----- --------- (Complete 1n 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. JOB ADDRESS AND LOCATION------------------------------ Owner's ----------- ----------------Owner's Name---------------------------------------------------------------------- :_---------- --------- --- -------------------------------------- Phone------------------------------------ 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--"----- 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: (If yes,date----------".------- I 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 clearest well.................Distance from foundation,-------.-----------Distance to nearest lot line----.-"-__..____- ❑ Number of-lines--------------------------------- Length of each line_- -------------------------..Width of french----------------------------------- Type of filter materia!..................__-'Depth of filter material----------------"------Total length------------------------------------------ Seepage Pit: Distance to nearest well-------------`------"Distance from foundation--------------------Distance to nearest lot line_____-.-__-___ ❑ Number of p s--- ---------------...Lining material---------------------- Size: Diameter-------------------:---Depth__.-----------------_------ Cesspool: epth-- _.-----------------"""------ Cesspool: Distance from nearest well ---------------Distance from foundation................. .Lining material--.---____________-.__-------.____-_ ❑ Size: Diameter- ------- ----- ------------2---Depth---------------- - ------- --- --- --- t---...Liquid Capacity------ ---------------------gals. Privy: Disfance.from nearest welt-------------------------- ------------ ---------Distance from nearest building---------------------------- ----------- El -- -----.❑ Distance to nearest lot line -------- ----------------------------------------------------------------=.----------------------•---------------------------------------- Remodelingand/or repairing (describe :------- - -------------------------------------------------- ----------------------------------- ------------------------------------------------------ ---------------------------------------------------------- ------------------------------------------------ ----------------------------------------------- --------- -------------•----------------- --------------------- --------------------------------------------------------I------------------------------------------------------------------- --------------------------------------------------------- --------------------------- -"-----""----------------------------I-------------------------------------------------------------------------------- ------------------------------------ ------------•---------------------- - ------ -. 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 regulations of the San Joaquin Local Health District. (Signed) -- ---------------------- ---------------------------------------------------------(Owner and/or Contractor) B %-------------- 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 recommendations----------- ------ -------------------------- ----------------------------------------------------------------------- --------------------------------------------------- ------------- --------------------•------------- ------- ----------------------------------- ------------------------------------ ___r FINAL INSPECTION BY:--------:: ------------ ----- ---------- Date--- ---.----- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore street 205 West 9Th Stroet Stockton,California Lodi California _ ,.Manteca, California Tracy,California E.H.9 2M 1-67 Vanguard Press