Laserfiche WebLink
FOR OFFI US <br /> ______ ------------------- APPLICATION FOR SANITATION PERMI Permit No. .. ........ ....... <br /> (Complete in Duplicate) f <br /> - This Permit Expires 1 Year From Date Issued Date Issued <br /> Application 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 /', <br /> . IAA4,�,�-,/3 <br /> JOB ADDRESS AND L . ATION-------- 9t- �.------ • - 0----------•----------------- - ----1------------- <br /> F <br /> Owner's Name .._1� ------------------------------------------ Phone.................................... <br /> AddressI? lc :[ -------------------------------------------------•--•---------------------------------------.............. <br /> Contractor's Name............. -------�U ` ------------------------•--..........----•----------------------- Phone................................... <br /> Installation will serve: Residence House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: J____ Number of bedrooms -__I-Number of baths __.-_ . Lot size -7-�7",x,/ ______________________________ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth -ro Wafter Table :;�d 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,date_- -----------) No [t]�New Construction: Yes ❑ No [ ANA: Yes ❑ No g. <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Ta Distance from nearest well--------- from foundation_____4.0_.___.M t rial__ca-ej�y -.---- <br /> _•� - •.__. q <br /> No. of compartments_-___�---__------Size__V-,!�!---------Liquid depth------K! -:______-_Capacity.. �.'_�?....... /— <br /> Disposal Feld: Distance from nearest well --------Distance from foundation------J.-4...(..Distance to nearest lot line--- <br /> ----- ---- -")'T ----------Width of trench---------- <br /> Number of lines...... .r__---_ .-__-Length of each line._ _ �----..--�-- <br /> ------------- V" <br /> - <br /> Type of filter material..:r'aGe---.­Depth of filter material---/If J..........Total length------- �z.d.�___________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------.----------------Dept h------------•-----._--.---------- <br /> Cesspool: Distance from nearest well-----_-----------Distance from foundation--------------------Lining material_.-.--------------------------------- <br /> n <br /> - .______________-__---._-____•❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------..................gals. <br /> Privy: Distance from nearest well ___________-------------------------------------Distance from nearest building------------------------------------------ <br /> [I Distance to nearest lot line- ---------- <br /> Remodelin and/or r airing (describe • _.._._ --- ------- ------- . _�_!1__�_ I <br /> -- ------ <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, rules and lations of the San Joaquin Local Health District. <br /> (Signed)----------------- IOwner and/or Contrectorl V- <br /> BY: --:.---� -------------------•-------------------------(Title)--- <br /> (Plot plan, showing size of to , cation of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------------------------------- -------------- -- ---------------- C/ DATE__ <br /> REVIEWED BY ------------•------------------- ... DATE <br /> BUILDINGPERMIT ISSUED.........-------------------------------------------------------------------------------------------- DATE----------------------------------- <br /> Alterations and/or recommendations:---------------------------------------------------------------------------------------------------------- <br /> ----------- <br /> ----••-•- -----••---•----------------------------------•----------------------------------------•-------------------------------------------------------•-•-•-------------------------------------.----•---------........ <br /> ---------------------------------------------••---------•--•------------------------------------------------------------------------------------------•----------------•-•---------••------------------------------••------ <br /> ---------•----------------------- - ---- ----------------------------•-- --------------------- ----------------------......------------------------------ -----------------••----------- <br /> FINAL INSPECTION BY:.-- C . Date•-----L'--15• V) •- <br /> --------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 305 Wed 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> E5 9 REWSED a-59 2M 5-62 ATLAS <br />