Laserfiche WebLink
f y <br /> APPLICATION FOR SANITATION PERMIT ---------- <br /> 0 !Y� (Complete in uplicate) <br /> Date Issued.. <br /> Applica�ion is hereby made to the ui oca Health D str' t f r a permit to construct and install the work herein described. <br /> This application is made in compliance wiCounty Ordinance 49. <br /> JOB ADDRESS LO TION.. !I__.. ._ - P. �,r�!�!° J__ ------ - ------ - r'� <br /> Owners dame F ----------- Phone Q--------------------- � " <br /> .: •--t - . <br /> � _ J ` <br /> Address---- _, ------ �` ;V------- -----f----- --- = - - - ----- -------------------------------------------- <br /> h <br /> Contractor's Name--- � t/L ----------------------- Phonc_ "� -2� <br /> Installation will serve: Residence *—A-Partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---I---- Number of bedrooms - Number.of baths -j""_._ Lotsize -------------------------- `fit <br /> WateF'Suiply: Public-systerh'❑' Commu"nity'"system"❑ PrivateA -Depth.-to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ 'Gravel E] Sandy Loam E] Clay Loam ❑ Clay [] Adobe Hardpan ❑ <br /> Previous Application Made: Yes FT—No ❑ New Construction: Yes ❑ No [�-�-- <br /> Y <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: i <br /> (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tan : Distance from nearest well-----------------Distance from.foundation--------------------Material---________.____-_____-_-__-_--___-.-_----__--. <br /> No: of compartments--- -------------------Size--- 3=--------- ---------Liquid 'depth--------------------------Capacity----------------------- h <br /> Disposal Field: Distance from nearest well-._��d----.Distance from founclation___.- -- <br /> �2__..___.Distance to nearest lot line.__t.�- -__--. <br /> .Number.of'.lin`es,__� -_ _.�__ ---_" --Length of each line------ "-.-"_-Width of trench-_ _-_ _tl__`r_-__-_-____---- <br /> 01 <br /> Type of`filter material---- -Depth of filter material--_;f -__R;-----Total length"---f Q------------------------------ <br /> r- ----------------------------T Y <br /> Seepage Pit: s t a to nearest well.--�_Q-a-._.--_Distance f om fo}}��ndation--.->�0-__-_._.Distance to nearest lot iin�---�'-""----_ <br /> q Diumnce ber of pits---'/--"---"---------Lining material_-, '�fi.....Size: Diameter-j4--------------Depth-----4-,-------------------- <br /> Cesspool: Disfance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- <br /> dEl iSize: D.iameter----11F.`---`--------------------------Depth------------------------------ ---------------------Liquid Capacity gals. <br /> /11 Privy:. - '_ ''Distan e'fro n nearest well!------------------------------------------------Distance from nearest building------------------------------------------ . <br /> f[-7� --- Distance to nearest lotline:.:.±'_T~' _ - ' <br /> . -4 <br /> Remodeling and/or repairingh(de`sc'ribe)------------ •-----------------------=------------------------------------------------------------------------------------------------------------ <br /> ----­--------------- <br /> — .... .y ,.i <br /> -- -----•------------------- ••--_-"---__--_---_----._.....-_"-.....-...-..-_- <br /> s <br /> .l;hereby.certify.the+.[ have-prepared this application and-that the work,will-be done:in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the`-San Joaquin Local Health District. <br /> • I � <br /> ,(Signed)---- - " ----- •- - ----------------------------- --------I Contractor} <br /> By:------- -------------------------------------•-..--------(Title}_- �. '`fi --------------------- <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 /> z : <br /> APPLICATION ACCEPTED BY---------------- ----- ------------ ---------------------------------------- DATE-------a b <br /> Y;V`[-- <br /> REVIEWED BY.=-----n----------------------- --------------------- --- --------- I----------------------------=-------- ------ DATE------ -----------------v[_u74------ <br /> REVIEWED <br /> PERMITISSUED---------------------`----------------------------:.....---------------...-----------------------•--.- DATE------------------------------------------------ ---•-•-----• <br /> Alterations and/or recommendations--------------------------------------------------------------------------------------------•--------•-----....` .. <br /> ----- ----- <br /> ------------_.-__----------------------- ---`--`---------------------------------- ---------------------------------------•- ---------------..-..-•----------------....---•---._..._---------------...------------------- <br /> • i <br /> FINAL INSPECTION BY:. v!/c(/ Date-- 1..I/--.. C-- / <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 />