Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
FOR O FI E FUSE:= r <br /> 3 'I" <br /> f <br /> 7_�tf� 3.-- -. piPPLICATION OR SANITATION PEr.MIT rmit No. (... <br /> -----------------,____-- {Complete-.in Duplicate) G� <br /> --------------- <br /> ____________ This Permit Ex ires 1 Year From Date Issu Date Issued __- <br /> ---------------- <br /> Application <br /> __- .� <br /> Application is hereby made to the San Joaquin Local'Health District for a permit i oust uct anO install th herein cribed. <br /> Thisapplication is made in compliance with County Ordinance No. 549.---- ---•---- <br /> JOB ADDRESS AND LOCATION- - - - � ------------------------------------. <br /> � y --- <br /> Owner's Name-- ---- ------- -----------------------�`-`-"-�--•----•--•-•-----------------------•----------- -----��'��---�- "-�---._ Phone--------------------.....-------._.. <br /> Address --------- --=----------••--------------------------------- <br /> Contractor's Name.-.- .= =------- Phone <br /> Installation willIserve: Residence ❑ Apartment House ❑ Commercial ❑'- Trailer Court ❑ Motel ❑ Other <br /> Number of living units: -------- Number of bedrooms -------- Number of baths _'..____ Lot size ------------------------------------------------------------ <br /> Water Supply: Public system ❑ Community system-E] Private Depth To Water Table 0/ tt. <br /> Il - <br /> Character of soil +46' a depth of 3 feet::. Sand E] Gravel ElSandy Loam F] Clay Loam ElClay C-] Adobe 0--Rardpan C) <br /> Previous Application Made: llf yes,date__________________-),, No New Construction: Yes .❑ No,�F.HA/VA: Yes E] No <br /> .0 <br /> �^ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> ( <br /> sep ,c tank or cesspool permitted if public sewer is available within 200 feet.) l <br /> o ti <br /> Sept' Distance from nearest well-----------------Distance from <br /> I! foundation.-______-_---_--___.Material________--_--_-_____________------._________-___. <br /> Liquid depth capacity Noof compartments------------------------ Size..--- <br /> Dispo �Fie "'6 Distance from nearest well_(_U'--.`.._Distance from foundation___t<t¢._f---------Distance to nearest lot line... ........ <br /> Number of lines----- -1 ---._Length of.each line-:_ -------------------.Width of trench_PZAe.--------------------- <br /> 4 i� Type of.fil.ter material._._/_�+l i -------Depth of filter matertj'-------------Total-length----.�__-Q--------------------------- <br /> t <br /> � <br /> Seepage-Pit: !I Distance to nearest well__/Q q____________Distancom foundation_1D_.r _._......__..Distance to nearest lot line__p---- <br /> [ Number of pits-------f------------Lining material__/ bG--4-t___-_Size: Diameter-Aa--- ___-.____Depth__.__.Z, ------... <br /> F Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining-•material_�_-):-_____/_......._.__.___-_ <br /> ❑ Size: Diameter-- -----------------------------------Depth------------I--------------------------•-- --------Liquid Capacity----------------------------gals, <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______-____--.._-__-___._.____.__.___.._.` <br /> ❑ Distance to nearest lot line------------------------------------------------ --------•----------••- -----------------•-------•----------•-•---•--------------------------- <br /> 1 � <br /> Remodeling and/or repairing (describe):------------------11-----------------------•-•-------------•-•-••---------- .....................-----------------................................ <br /> ...... <br /> -•-•--------•----••------ ------•-----------------------=•------------------•------------- ----•----------------------------- ---- <br /> --------------------------------- <br /> -----------------­--------------------------•-----------------•�---•----------------------- = ----------•-------------•------------------------------•------------•---------------••-------------------------------- <br /> --------------------------I� <br /> 1 hereby certify that•1 have prep this pplicafion and that the work will be done in.accordance with San Joaquin County <br /> ordinances, State laws.-and rules an gulat- ns of the an Joaquin Local Health District. <br /> (Signed)----------- '---•----- = --------------(Owner and/or Coritractorl <br /> B :---...- i! .! .... ----------•--------------------------- -----------------(rifle) ---- - --------------- <br /> -.------- ---------- <br /> Y - <br /> (Plot plan, showing size o lot, I ati of syste n relation to wells, buildings, etc., can be placed on reverse side). <br /> r, <br /> i� 7 FOR DEPARTMENT USE ONLY_ <br /> APPLICATIONi ACCEPTED BY-------------------------------------------------------------------- <br /> I_ DATE ---- - -----__6- - •-- <br /> REVIEWEDBY' ---------•------------- --------------------------- ----------------------------- --------- DATE <br /> BUILDING PERMIT ISSUED---------------•----------------------------------------- •------------------ : = DATE <br /> Alterattions ani <br /> -------------------- - /or recommendations---------------------------------------.-------- ............. <br /> ----------•-•--------------..-----••.... - <br /> 20-:7:i&_-3.............. ---- =------------- ------ ----------- ---- -- . .---------- <br /> =!°- ------------ ----- ----- ------- -------------- -------- ------ <br /> ---•-•-------- II <br /> FINAL INSPECTION ------ ---•------ --------- Date--.- ----------------------------------- <br /> SAN <br /> ---- -- <br /> ------•---------•---•--••-- <br /> SAN • <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South Allli merican Street 300 Wast Oak Street 144 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California + <br /> CS 9 REVISED 8-59 ZM 5-62 ATLAS <br />