3445 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR SA (P� A� NITATION PERMIT Permit Noj.1_4.-�_-- (Complete in Duplicate) I Date Issued -__-�.a. Application is hereb made to the / Y San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-----------.2 �- -----------------------------------------------;------------------------------- Owner's Name---------------------------------- ----- • �', ji'�; ,� -�- � -------------------------------------- Phone- - ------ A rase f_��_ i s f 1 ___________________________ -_._fw��✓._`-mfr _.___ + _�-- G� .!�1. /: ---- ----------------------------------- Contractor's Name ---- :' t( -- ---------------- ----------- - --------------- —---------------------------------------- Phone Installation will serve: Residencep -�-�---' ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E]Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ___ _ ___ ____ Water Supply: Public system ❑ Community system El Private [3 Depth to Water Table -------- ft. _______ ____ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation---_---_.- pth--.Material ---------------------------------- ❑ No. of compartments_.___._._---_-_____---Size----------------------------- Liquid depth ----------------Capacity--•--------------- Disposl Field: Distance from nearest well_ _Distance from foundation-.--.-_.___.-_---_-Distance to nearest lot line______.----____ ®/ Number it lines---erial------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-_._.___.____-______Depth of filter material_._..___-.___-_____Total length---------------_------................... Seepage Pit: Distance to nearest well ___----__-_.___ Distance from foundation ------------------Distance to nearest lot line ❑ Number of pits.__------------------Lining material_._ -------------------Size: Diameter-----------------------Depth--------- -- --------------------- Cesspool: Distance from nearest well-----------------Distance from foundation___-___-_____--__.Lining material--._-_--.._-_-_______-___-_ ❑ Size: Diameter-------------------------------------- Depth---------------------------------- Liquid Capacity ale. ------- -------- -------- ------------g Privy: Distance from nearest yell_ _ ❑ Distance to nearest lot line-------- ___.Distance from nearest building-------------------------------------- __ -------------------------------------------------- ___ ___ _____ _____ Remodeling and/or repairing (describe):-*--- ------------- -------------------- describe): f --------------- - --- ----- ----- ---------------_-- _ y.�.,. ei. �.�--------------------- - - --------------- ----- - -------------------------- -------------------------- - �I-- 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 regu ations of the San Joaquin Local Health District. (Signed)---- ;_ ---------------------- ---------------------.._.(Owner and/or Contractor) • By:--------------------- ------ � ` - (Title) -------------------------------------------------- P of plan, showing size of lot, location of system in relation to wells, buildin s etc., can be laced on reverse side). g ' P FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ________ --- - ---------------------------------------------------------------- REVIEWED BY - DATE--------------- BUILDING PERMIT ISSUED--------------------------------------------------------------------------------------------------------------------------------------- �_ Z S --------------------------- Alterations and/or recommendations-.--' ----------- -------_--------------------`- DATE --------- ------------------------------- ------------------------- FINAL INSPECTION BY: ---------------- Date------- � - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street S+oak+on, California 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M I0-52 Revised W-2100