Laserfiche WebLink
C� APPLICATION FOR SANITATION PERMIT Permit No. ..`'......... ...... <br /> (Complete in Duplicate) b <br /> 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 <br /> . No.JOB ADDRESS AND LOCATION_.- - .... <br /> ..................... <br /> Owner's Name----�-'----- ---------------------------------------------------------------.------ <br /> ---------------- Phone................................... <br /> Address........Za---�24- 0-------------154. -- - ------------ ............................................................ <br /> �/' <br /> Contractors Name r Phone ! ,f^2 �... <br /> Installation will serve: Residence (I Apartment House 8—Iffornmercial 0 Trailer Court ❑ Motel ❑ Other ❑ <br /> -Number of living units: _ Number of bedrooms __4y_ __ Number of baths ./ _ Lot size ....kw'1-2-_ ...... ..................... <br /> Yater-Supply: Public system ammunity system ❑ Private ❑ Depth to Water Table <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe14-11ardpan ❑ <br /> Previous Application Made: Yes ❑ No 4—New Construction: 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 wellx __-_Distance from <br /> �-_ foundation..../Q ...... <br /> Material.._ ---------­--- <br /> ----- -4 <br /> ._..._.No. of compartments______-�. ------------Size.. __ .......Liquid depth_:�_ ---------------� Capac1A <br /> Disposal Field: Distance from,nearest well-----------------Distance from foundation.... ..___.Distance to nearest lot lineX__-_-_----. <br /> Number of lines------------/____ jr._ Length of each line_____2 ------------Width of trench._- -_ _`---_-_-__________.__ <br /> Type of filter material___l z____� Depth of filter material-----I�_-_'__'----Total length......._. ,5=__`....................... <br /> Seepage Pit-, Distance to nearest well----------------------Distance from fo ndation...1.Z.`..._..Distance to nearest lot line.S i...__..__._ <br /> �- Number of pits------/-------------Lining material--- Size: Diameter-----1 c5?... Depth----.Z.S-f-................. <br /> Cesspool: Distance from nearest well_________________Distance from foundation-------------_----Lining material-------------------------------------- <br /> 0 <br /> ---_-_.___.- -_ .-__---_ __--.❑ Size: Diameter---------------------------- --------Depth----•------- •---------------- --. Liquid Capacity-----------------------------gals. <br /> Privy% Distance from nearest well____ __ __ __ _________________ ______ _Distance from nearest building------------------------------------------ <br /> El <br /> _________________--.-----•--__.__-__.-.❑ Distance to nearest lot line-------------------------------- ------------------------------•--------------...--••--------.._..-----------•----------..._........------.--- <br /> Remodelingand/or repairing (describe):------------------------------------------------••-•----------•--------•-••--------••-•---•-•--•------------•-------._.---•---••-----------•---•------- <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,USe , and les and regulations of the San Joaquin Local Health District. <br /> (Signed)-•--- •... ---- ----- -- - ---------------------- tww 's Contractor) <br /> yam,-/ / <br /> BY: 1� i!'?.1-�/,�--G-- �^--- (Title) �2 ! ? ' <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 /> APPLICATIONACCEPTED BY--------- --_- -- - ---- ------------------- -----------------------•---------------• DATE...... ----•---------------------------------------- <br /> REVIEWED BY DATE y------------------------•-------------- <br /> BUILDINGPERMIT ISSUED-•---------•--------- -•---- = .....................................................----------••-- DATE------------. ---cit---------------------------------- <br /> Alterations and/or recommendations---------- ------ ---- -•-..lF-- ....................... <br /> --------------------------------------•- ------------------------•...................... ............................................. ---------------------------------•-------------------- •----------•----- <br /> ------------------------ -------------------- ------------------------------------------------------------------•---------------------------------•------------...----------------------------•-------------=--------- <br /> ,el"I Alw-z A- `?, . .f j-.;- <br /> FINALINSPECTION BY:- •----- - ----- ---- -------------- Date....----------------------3..................................................... <br /> SAN JOAQUIN LOCAL 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 /> ES-9-2M Revised W-2100 <br />