Laserfiche WebLink
FOR OFFICE USE: <br /> ------------------------------ -------------------------- <br /> --------------------- - - - <br /> APPLICATION FOR SANITATION PERMIT Permit No. <br /> ------- -------------- --- --------- <br /> -------------- ------------------ ------------- (Complete in Duplicate) <br /> Date Issued <br /> - <br /> -------------------------------------------------- <br /> -.--" This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the w rk herein described_ <br /> This application-is made in compliant with County Ordinance No. 549. 1"6N S, C-worS <br /> JOB ADDRESS LOCATION/%_—_- /--�" ----- -- k --•----- <br /> Owner's Name- ----------• --------------- --------------�--- -jPhone--------------------------------•--- <br /> - <br /> —? � - -Address-----••-------------11 - ----- -- --- <br /> - -------- <br /> Contractor's <br /> ----- -Contractor's Name -rte - ------�... ----- Phone....1_--------•-----_---•--•--- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [Other ❑ <br /> Number of living units: ----r-- Number of bedrooms -��Number of aths __I---- Lot size <br /> ----/ <br /> Supply: Public system ❑ Community system ❑ Private Depth to Water Table ........ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe ❑ Hardpan F1{ <br /> Previous Application Made: (If yes,date-----------------_.} No F1New Construction: Yes ❑ No E] FHA/VA: Yes ❑ 'No ❑ "+ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: I ; <br /> (No septic tank or cesspool permitted if public sewer is available within 240 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material---------------_--------------------' <br /> ---------- <br /> ------------- ---Liquid depth------___.--------_. --Capacity t----------- <br /> . f <br /> ❑ No. of compartments--------------------------Size.-------------- a I <br /> Disposafield: Distance from .nearest well__X6__r_---Distance from foundation_ AD_--.-_.-.-Distance ' <br /> to nearest lot,line-- V---------- <br /> Number of lines--------------I-------------------Length of each line-----5 "f-_--_------.Width of french----�-- ---------------------­ <br /> Type of filter material--_----Sy -----Depth of filter material ----�__/--9-_r_`__..Total length---.---- .4j---.---.- '--------_-- . <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-------------- ------------------------------ ------Liquid Capacity- ------------------------gals. <br /> Privy: Distance from nearest well .--------------------------------------"----Distance from nearest building-----_---__-.--------____--.-.-:.---. -. <br /> ❑ Distance to nearest lot line------ --------------------------- -------------------------`----------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):------ ------------------ -------------------------•---------------------------------------------------------------•-----------------------`------- <br /> -------------------•------------------------------------------------- ------------------------------ <br /> - -_ - - _---....----------------------------------------"-"-------------------------------------------------------------"---------------------------------------" - <br /> I hereby certify that I have prepared this application and that the work will-be done in ard2ordiSnce with San Joaquin County <br /> ordinances, State I , and rules and regulations of +he San Joaquin-Local_Htaalth District. <br /> ----------------- -- - -------- - ------ --------------------------------------------------------•------------- and/or Contractor) <br /> (Signed) <br /> C �� -------------------------(Title)-------------------------------------- --- <br /> By: f� <br /> -- - .--- ---------- --- - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY------------- r <br /> �' `j # <br /> - -- =----- - ----------- ---- --------- ---------------- -- DATE------�"----------- -=G�---------------------------- <br /> REVIEWEDBY-------------------------------------- -------- ----------------- -------------- ----------------------------------------- DATE--------------------------------------------------------- k N <br /> BUILDINGPERMIT ISSUED------------- --------------- -----------------------------–-------- ----------------------------- DATE----------- ---------------- - ------------------------------ q <br /> Altera+ions and/or recommendations: ---------------- ------------- <br /> D <br /> ' -------------------------------• ---------------•--"------------------------------------------- <br /> F ----------------------------------------------------- ----"------------------------------------------------------- ------------------------ -- ------------------------------------ <br /> ------------------------------------------------------ ----------------------- --------------------------------------- ------- <br /> FINAL INSPECTION BY:----------- -- ------------- Date-- -----' � ��----------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Avrr. 300 West Oak Street 124 Sycamare Street 205 West 9th Street <br /> Stocktonr California Lodi,California Manteca, California Tracy,California <br /> III F.P.CO. <br /> !1 <br /> 1 <br />