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APPLICATION FOR SANITATION PERMIT Permit No. ------------------- <br />(Complete in Duplicate) Date Issued _______________________ <br />Applica;ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br />This application is made in compliance with County Ordinance No. 549. <br />JOBADDRESS AND LOCATION ----------------------------------------------------------------------------------------------------------------------- --------••--------------------------------- <br />Owner's Name -------------- ---------•--------------•------------------ ------ ------------------------------------- Phone --------------------• ------- <br />r rl. - . <br />Address------------------------------------ -------------------------------------------------•-••--------------------------------•--------------- l- --------- -----•-• ---•----•-----------•-•-------•- <br />Contractor's Name ------ ------------------------------------ `-------------------------------------------------------------------------- .............. Phone ---------- ------------------------- <br />Installation will serve: Residence [_1Apartment House E]Commercial ❑ "Trail'e'r. (Court ❑ Motel ❑ Other ❑ <br />Number of living units: _______ Number of bedrooms -------- Number of -baths ________ Lot size____________-_____________________________________________ <br />i' <br />Water Supply: Public system ❑ Community system ❑ Private E] Depth to Water Table` ________ ft. <br />Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam <br />m ❑Clay Loam ❑ E]',Clay ❑ Adobe ❑ .Hardpan ❑ <br />Previous Application Made: Yes ❑ No F-1New Construction: Yes E]No E] <br />TYPE OF INSTALLATION AND SPECIFICATIONS:. iI <br />(No septic tank or cesspool permitted if public sewer is available within 200 feet.) ��. <br />Septic Tank: Distance from nearest well________________ Distance from foundation ------------ _______.Material------------------------------------- <br />------------ <br />❑ No. of compartments-------------------- -----Size:" - ------------------- : ------ ---Liquid depth--- - -------------------- Capacity ----------------- <br />11 <br />Disposal Field: Distance from nearest well..................DD &nce from foundation -------------------- Distance to nearest lot line ----------------- <br />❑ Number of lines ---------------- ---------------- ---Length of each line --------.--------------------.Width of french ----------------------------------- <br />f Type of filter material ------------------------(Depth of filter material ----------------------- Total length ----------------------------------------_- <br />Seepage Pit: Distance to nearest well ---------------------- _Distance from foundation .................... Distance to nearest lot line________________ <br />❑ Number of pits---------------------- Lining material--. -------------------- Size: Diameter------ ---------- -- _Depth--------------------------------- <br />Cesspool: Distance from nearest well ------------- _--- Distance from foundation_-_---- ______-_.Lining material ------------------------------------- <br />❑ Size: Diameter-------------------------- -----.Depth"-=-1.--------------------------------------------Liquid Capacity ---------------------------- gals. <br />Priv Distance from nearest we1l ---------------------------------------------4.-Distance from nearest building ------------------------------- <br />❑ Distance to nearest lot -line_—` '."_____-.- ` ` <br />----------------------•--------------------------------------------------------------------------- ....... <br />Remodeling and/or repairing (describe)____________________________, y <br />f n <br />---------------- <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, State laws, and rules and regulations of the San Joaquin Local Healih District. <br />Owner and/or Contractor <br />By:--------------••-------------------------------------------------------------------------------------:---------------------- (Title)--;- ------------------•---•------------------ ----------------- <br />.(Plot plan, showing size of lot, location of system in relation to wells;%uildings, etc., can be placed on reverse side). <br />.h <br />FOR DEPARTMENT USE ONLY1 <br />APPLICATIONACCEPTED BY ------------------------------------- - ------ ---------------------- :--------------------- DAT'E ------------------------------------------------------------ <br />REVIEWEDBY-------------- ------------------------------ 41------- ------------------------------------- •-------- DATE ------------------------------------ •----------------•------ <br />BUILDINGPERMIT ISSUED --------------------------- ------------------ J ----------------------------------------------------- DATE-------------------------------------------------`--------- <br />'------------- <br />---------------------------1r` <br />---------------------------------- ----------•- ---•--Alterations and/or recommendations: ----___.__.___-.------------------ <br />---------------- <br />--------------------------------------------------------------------------------------------------------------- ------------ ----- <br />-----------------------------------------------------------------•------------------------------------------------------ ---------------------------------I---------------.....-•---------------------------------- <br />----- <br />-----•------------------------------------------------------------------------------------------------------------------- -------------- <br />------ ------ ----...------------------------------------ _..--------- <br />II <br />r---------------------------------------------------------------------•------ --- ----- <br />y� <br />.It <br />FINALINSPECTION BY------ (---------------------- ----------- ----------------------- Date. ---------=•":- ------------------------------------------------•------- <br />1, <br />SAN JOA -U#N-L:OCAL HEALTH DISTRICT <br />130 South American Street 300 West Oak Street 132 Sycamore Street 814 North C Street <br />Stockton, California Lodi, California Manteca, California Tracy, California <br />E5 -9-2M Revised W-2100 j <br />