21838 - Laserfiche WebLink

Home Browse Search

,j rUK Urr (-t USE: -------------- ------------ --------------------------- ------------- - ------------ -------------------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ---------------------------- - ----------- {Complete in Duplicate) '----- ------ This Permit Expires i Year From Date Issued bate Issued ' Application is hereby made to the 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, 544: Lo OS !V176. !40 JOB ADDRESS AND LOCATION ? _,- - iZ v.+ Owner's Name '----- ------ ------------ !J Phone -- ------ Address _ -tQa ~ ` -- --------------------------------------- Contractor's Name ... ---I' - ,.� �„� ----- -- --------------- ---------------- Phone _ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ` Number of bedrooms _ -- Number of baths l------ Lot size ------------ �s Water Supply: Publicsystem El Community system ❑ Private Depth to Water Table ---- ft. ft. ^� Character of soil to a depth of 3 feet: ;Sand ❑ Gravel any Loam Clay Loam E] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made:. (If yes,date_______________ ____1 No ❑ New Construction: Yes ❑ No ❑ FHA/VA: 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--------------------Material_._____..____.____-____ . ❑ No of compartments--------- -- ---_Size-------------------------- ---Liquid depth---------------- ---------Capacity- Disposa field: # Numance from lines earest �eff - 0- -Distance of each line foundation l�p� ----Distance to nearest t line_____5__`- _- g --------------- - Width of trench -- - --------------------------- -------.Type of filter material_______ -rZ� Depth of filter material-----ti-;------------Total length-----/-ap-- ------ - - ------------------ Seepage Pit: e Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line___...__.__ ❑ h Number of pits- t------------------Lining material--------------------- -Size: Diameter------------- --------Depth------------------------------ Cesspool: A. Dirstance from nearest weft-----------------Distance from foundation___._...______.._...Lining material............---_---------------------- ❑ Size: Diameter fi = Depth --------------------- ---- ---------------Liquid Capacity----------------------------gals. I Privy: 'Distance from nearest well_..__._.__-------.------- ----- --------------Distance from nearest building- Distance to nearest lot fine___________________________ _ ------------------- -----------------------------------------------escrii�e�: -- •-- ------------------------- Remodelingan or r a�r3n d �� .�------ � �,.�-y - ----•------- ----------------------------� -------------,� p g � _ ----------_---------------------------_.----------------------- ___- __.-- _______________-___________.___.___________-_________________.__-_.________-__._..._______-___._______________._-___....___._.____.__-__..____ I hereby certify that I have prepared'#his application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules andq regulations of the San Joaquin Local Health District. (Signed} t r �. - Si . .� - ---------------� c and/or Contractor y .-..=------- ---------- ----------`---- --- --- - Lbeplaced .. ---------------------- . � Y . --------------- (Plot ... plan, showing size of lot, location off system in relation to wells, buildings, etc., con reverse side). r � . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_.__- -g DATE---=�� --- �!7_- 7 ------- ----- REVIEWED BY ------------------------------ ----------------------- DATE-------------------- UILDING PERMIT ISSUED------------------------------------------------------------------------ ----------------------------- DATE Alterations and/or recommendations:_____................ ---------- --------- ----------------------------------------- --- ------------------------------- -----11---------- ------------------------------------------------------------------------- ---------------------- ------------- --------------------- ---------- ------------- ------•---•--- ---- ----------------------------------- -- •---------------------------------------- ------ --------------------------- ! FINAL INSPECTION BY:.. �-i--� --_--_---- Date_ r ! C SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E.Noxeiton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.RCQ.