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APPLICATION FOR SANITATION PERMIT Permit No. ___________________ (Complete in Duplipafel -_ Date Issued ----------------------- Appli cation 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 t'with County Ordinance No. 549. t JOB ADDRESS AN:1 LOCATIONI__!.e t"4_y_� — v ' 4-0 + - , --- - ..__._-- ------------------------------ --- = . Owner's Name ----------------- � �. -------------------- -----------'----------------------------- Phone-------------- ; tr • Address------------------------------------------ -------- ----------------------•---- = Contractor's Name----------------------------------------------------------------------------------------------------------------------------------------------- Phone...........................-------- f Installation will serve: Residence ❑ Apartment.House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:-_______ Number of bedrooms ._______ Number of baths ________ Lot size _ _______________________________________..____t__._---..__ Water Supply: Public system ❑, Community system ❑` Private E] ' 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 fee+.) 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...... ----------- El of lines_'--------------- Length of each line------------------------------ of trench----------------------------------- Ty�e 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 piW-l�------------------Lining material--------------------- Size: Diameter--------------------------Depth----•---------------------------- p Size: Diameter__ -------Distance from foundation------------------- Lining material-------------------------____-_.____. f ❑ i f ----- Dept h----------------------------- ----------------------Liquid Capacity----------------------------gals. ` Cess ool: Distance from nearest well-_-.______ Privy: Distance � rr�om n Barest yell -----------------------------------------------Distance from nearest building____._ Distance�to neo ❑ �est•lot Ime - Rem--o-d--eling and/or repairing (descrrtibe} iT i --------------------------------------- __-------------._--------------- + 1 ------------------ I•hereby certify that.I have prepared this application and that the work will be done in accordance with San Joaquin Coun+y ordinances, State laws, and rules and, regulations of the San Joaquin Local Health District. (Signed) ----------- ,.- -------------------------------------------------(Owner and/or Contractor) .. . - 34i 13 1 , .. -------• Title (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). f " FOR'DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY- -----=- ------------------------------------------------------------1------------------------•--- DATE-------------------- REVIEWEDBY = = -------------- ---------------------- ------- ----------------------------..". DATE--------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------4------------------------------------------------ DATE------------------------------------------ Alterations and/or recommendations:----------- --------------------------------------------------------------------------------------------------•----------------------•---------------------- - tri - - ------------- - 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 B-9-21x1 : Revised 1.57 F.P.CO.