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APPLICATION FOR SANITATION PERMIT Permit_No. ... ? 7 1 1�1 (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 Count Ordinance No. 549. -7 JOB ADDRE55•A D 1 ATfON...�-- h� . -- ------------ = ----------------------------------------------------- Owner's Name-- -- -- - ----- - ------ --------- ---- --- ---•--------- -----•-----------------------------------------------------------------._. Phone--------- - --•-------- Address " -•------------- -- ---------•----------------•----------------------•----------------------- -.......•--------------------------------- Contractor's Name----- ---- -- ------ -- --•---•----------------------------------------------------------•----•------------------------------. Phone----------------•-•---------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑' Zofelr❑ Other (] Number of living units: __/--- umber of bedrooms _-Z. Number of baths __/___ Lot size ______ . _10 ----------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Wafer Table ---------ft. Character of soil to a depth of 3 feet: ' Sand ❑ Gravel ❑ Sandy Lo;'PNo Clay Loam [3 Clay ❑ Adobe Hardpan [IPrevious Application Made: Yes E] No W New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted iv ublic se er is available within 200 feet] Septic ank: Distance from nearest well___ �isfancV from,fou 4tion�4__ . at ri�l_____ ____ _ _ ___ I -- ---- -------- No. of compartments__._-- -_--Liquid c�eptb--,---," `--------------CapacitY-•---- --- (,<r Dispos Field: Distance from nearest e!L_ _______'' -- istance from foundation/V. :kJistance to nearest lot line _,ff Number of lines._---_-__ ____ --__-- Length of each line________.�- Width of trench._____ __ " _ _r._.___. TJ Type of filter mate p g �Be th of filter material______ _______=___Total length _ __�______________ Seepage Pit: Distance to nearest well______________________Distance,from foundation_-..____________---.Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material------------------------ Diameter---------.-------------.Depth-.----.-------------------------• Cesspool: Distance from nearest well-----------------Distance from foundation--------------.____.Lining material-------------------------------------- F-1 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]:------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ ---"-----------------------------------------•----------------------------------------------------------------------------------------•------------------------ ------------------------ 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. , . 1 (Signed)__ ------ (Owner and/or Contractor) By: (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 BYDATE -----• ••------ --------- - ----------------- REVIEWED BY ------- ------------------------------------- DATE__' BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE_ Alterationsand/or recommendation's----------------------- ---------------------- -----------------------------------------------------------V------------------------------------------------- ----------------------------------------------- ---------------------•---------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------•------------- --------------------------------- -•------•--- ------ ------- ------------- ---------------------------------•-------------- --------------------------------------------------------- ------- ---------------------------------------------------------- g FINAL INSPECTION BY-------------'--- /ci��--------- Date............. :. - --- ----- --------H 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-4-2M �0-52 Revised W-2100