Laserfiche WebLink
APPLICATION FOR SANITATION PERMIT Permit No. .__rp_ _, __ <br /> (Complete in Duplicate) 3 <br /> Date Issued <br /> Applica+ion is hereby made to the San Joaquin Local Health Di rict for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance lo. 549. <br /> JOB ADDRESS AN �OCLqION�;; �' ---------- <br /> Owners Name. = Phone ,_ 2 <br /> Address-_._._ - `� ------------------------------------- <br /> Phone, <br /> -------------- <br /> Contractor's Name________________________ Phone __: ____ <br /> ---- 1 ---•-------- -- -----------------------------------------------•--------- -- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ----1 Number of bedrooms ._�__-_ Number of baths -- Lot size __ U_____________________ <br /> Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Tabl­'AP ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy <br /> \Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes F] No�' New Construction: Ye,0 No ❑ / \\ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) /j� <br /> Septic Tank: Distance from nearest well_"_)_r__Distan e from foundation __r-____.Material__.` __ ________________________________ <br /> No. of compartments.�---_-._----..----$ize����-��--Liquid depth_��__�f'3-�----Capacity---�s�--�----- I <br /> Disposal Field: Distance from nearest well--,__0__ -_Distance from foundation_✓G__.-_..--Distance to nearest lot line---- `...__. <br /> Number of lines__-}/----------------------- Length of each line_.____- d__�i...._...Width of trench-----___-------------------- <br /> - <br /> _ <br /> ------Total lenth--------- ---emsTYpe of filter material _ c-___-Depth of filter material <br /> Seepage t <br /> Pit: Distance to nearest well from foundation to nearest lot line_-____-_________ <br /> ❑ dumber of pits----------------------Lining material---_-------------------Size: Diameter_.-------------------Dept n.......--------.----------------- N <br /> Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material_-____--____---_____-_______________. <br /> ❑ Size. Diameter------ ---------------- -------Depth---------------------------- ---- ------- --------Liquid Capacity----------------------------gals, <br /> Privy: Distance from nearest well------------------------------------------------Distance from nearest building-------------------------.----------___ . <br /> ❑ Distance to nearest lot line-----------------------------------------------------------------------•--------------- ----------------- ------------------------ <br /> Remodeling and/or repairing {describe). - M� x -a -_ ------ - -»-........_---------------------------------- <br /> -------------------------------------------------------------------- ----------------------------------------------------------------------- -------------------------------------------------------------------------- <br /> -------------------------- ----- ----------------------•------------------------------------------------------- <br /> ------------------- <br /> ------------------------------------------------------•----- -------•-----------------•-------------------------•---------_-___---------••-------•--•----•------------------ ----------------------------------- <br /> I hereby certify that Ive prepared this application and that the work will be done in accordance with San Joaquin County ' <br /> ordinances, St ws, a uI and regulations of the San Joaquin Local Health District. <br /> r <br /> (Signed)....... ___ _. ____.____ ^,ced4,n <br /> Owner and/or Contractor) ! <br /> - --- -- ----- -By:--•--------------_--••---......,- = Q' '------ ---------------------------------------------------------------(Title)- _----------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be peverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ------------ --------------------------------- ------------------------------------------- DATE <br /> REVIEWEDBY----------------------- -------------- --------------------------------------------------------------- DATE ------------- ------ <br /> BUILDING PERMIT ISSUED----------� -- --------------------------------------------- DATE------ ---------------------------------------------•- <br /> Alterations and/or recommendations:-----------------------------------------------------------------------•----------_-----•-------•---------�--------------------------------------------- <br /> --------------------------------------------------------------• --------------- ---------------------------------------------- -------------------.....................--------------------••-------------------------------- <br /> ---------------- ------------------• --------------- ------------------------- ---------- --- ----------- ----------------------------------------- -------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------•----.-- ----------- ----------------------------------------------------------------------------------------------------------------------------------- <br /> FINAL INSPECTION BY:-------- --------- ------ ------------- Date_-. ----G---------------"------------ ----------•---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Streof 300 West Oak Street 132 Sycamore Sfreet 814 North "C' Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> E5-9-2M 145446 ATWOOD 12-54 <br />