Laserfiche WebLink
FOR OFFICE USE: <br /> ------------------- -------- ------------------------ I �- <br /> APPLICATION FOR SANITATION PERMIT Permit No ________________________ <br /> -.S o. (Complete in Duplicate) <br /> 1_----------------------------------------.-..:__.-___.___' . " {This'Perm if'Ex fres I'Year From Date Issued <br /> . Date Issued --.-- -`.--_---- <br /> ..._ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and in the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOBADDRESS AND LOCATION------ ­0 -----------•-------•--------------------- - ....----------......--------------•-•----- <br /> Owner's Name-- �1,�1t�1, - ......lji -------•------•---------------------- -----------•-------------------------------- Phone.----•------------••-----...------•- <br /> Address------------------------------------- �✓! ----------- ------------------------------------•----------------------•-•---•--------------------••-------------•----------------------------- <br /> Contractor's Name-------------------L�-• -----�--�---....�-�--1-•�--'-------------------------------- --•- --------•-------• <br /> ........................ Phone-----------------•---------------- <br /> Installation will serve: Residence n"-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ____:�__ Number of bedrooms __- Number of baths _�_..-. Lot size ....___2� xkl z _------------------------------ <br /> Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table 6_-- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe®Hardpan ❑ <br /> Previous Application Made: {If yes,da#e------- ---_---------) No ®" New Construction: Yes Ej-"No ❑ FHA/VA: Yes ❑ No ©' <br /> TYPE OF INSTALLATION AND-SPECIFICATIONS: <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_ .4------Distance from foundation.-_IU............Material_______________________________________________ <br /> l� ------Size-------��---- '` `-----•-Liquid depth_.y- CaPacitY---- <br /> 0 No. of compartments__.__-_- _ _ <br /> Disposal Field: Distance from nearest well._: sC__Distance from foundation..10--------------Distance to nearest lot line__5 ......... <br /> [?]� Number of:lines-----------------------------------Length of each line-------..3l1---------------Width of trenth______ -'�------------------------ <br /> Type of filter material___&o_,._,�_______-__Depth of filter material-__/�"_____-_--___Total length----____moo--________________________ <br /> . s <br /> Seepage Pit: Distance to nearest well___-��L_._____Distance from foundation_J_P..__`_________.Distance to nearest lot line--------______._ 1 <br /> ©­ Number of pits------f--------------Lining material----_D7R-P_�-------Size: Diameter----.3s- ---_--Depth------------- -------------- <br /> Cesspool: Distance from nearest well-----------------Distance from found ation--------------------Lining material------------------------------------- <br /> ❑ Size: Diameter---------------------------------------Depth-------- ---------•---------- I---------------------Liquid Capacity-.------------------------- gals. <br /> Privy.. Distance from nearest well-------------------__ ___--____-----------------Distance from nearest building------------------------------------------ <br /> _ <br /> _ <br /> ( ❑ 'Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------...-------------------- <br /> i <br /> Remodelingand/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --•-------------- -----------•-----------------•------------------------------------------------- <br /> � r <br /> t <br /> -------------------------------------------------------- - <br /> --------------------•-------------------------------------------------------------•••-•------------•----------------------•---------•------------------•--- ------- <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 regu atio s of the San Joaquin Local Health District. <br /> (Signed)------------------------------------------------------ ---- ------- - ---------- <br /> --------------------------------------------------(Owner and/or Contractor) <br /> I 'r Title <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 /> APPLICATION ACCEPTED BY ------ -----------~�---------------------- -----=-------------- DATE-----!7- 3� r l�'� ----------- <br /> --- <br /> REVIEWED BY------------- ------------ ,J <br /> - ------ DATE------------------------------------------------------------ <br /> .............. <br /> PERMIT ISSUED-------------------------------------------------- <br /> --------------------------------------- DATE-------------------------------------------- --------------- <br /> IAlterations and/or recommendations:___n_..-------:---- ---_--------------------••- - --- <br /> --��----- ,��--`-�•I----------��L .�.���. .-��....,. =�c - <br /> a <br /> ------------------ <br /> --------- - -------- --- --------- = ------ <br /> .4 ----------------------- ------------------------------ <br /> FINAL INSPECTION BY::.-_'...._ <br /> J Date.------ r ----------------------------- <br /> 'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> //RJCV15 D 8.59 F.F.CD.ZM 6-66 <br />