Laserfiche WebLink
APPLICATION .FOR SANITATION PERMIT Permit No_ ---­---------­----­- <br /> (Complete <br /> ___________ __________(Complete in Duplicate) <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 to <br /> with County Ordinance o, 549. 3 <br /> JOB ADDRESS ANDCATION________ ___ - = ------ ---- <br /> Owner's Nam -- --- ------ --� Phone. <br /> Address._ . <br /> --------- - <br /> Contractor's Name - f --------------------•------------> --------•-------------- ------ Phone--�-Z-X- �----- <br /> Installation will serve: Residence ] Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other E]` <br /> Number of livinunits: __ __- Number of bedrooms --- Number of baths ._f__- Lot size <br /> g <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabl _. ft. <br /> Character of sail to a depth o,3 feet Sand ❑ Gravel ❑ Sandy Loam ❑ -Clay Loam ❑ Clay ❑ AdobX Hardpan E]Previous Application Made: Yes ❑ No New Construction: YesX No El / t <br /> a <br /> TYPE OF INSTALLATION AND SPECI [CATIONS: <br /> (No septic tank-or cesspool permitted if public sewer is available within 200 feet.) <br /> r <br /> Septic nk: Distance from nearest well_________________Distance from foundation-------.------------Material---------------------------------------_____----- <br /> • No. of conipartmen ts---------- ----------`....Size---------------------------------Liquid depth---------- - -------------Capacity.._!-_--------------- <br /> Disposa ield: Distance from nearest well------------'__-Distance from foundation--------------------Distance to nearest' <br /> rot line_____-_...__._.._ <br /> Number of lines -C <br /> epti' <br /> ---Length.:of-each line:---------------- 'Width of trench.---------------------------------- <br /> •_ h <br /> Type of filter, mate'riaL__________________--._4Depth of filter,material_7..__-7.. -___Total length---___.____---_____-_--____________..__._ <br /> Seepage Pit: Distance fo nearest well_,r�" �- -- Distance f om f ndation____� ____-_.Distance to nearest lot:.line__--��w�._••__ <br /> Nuf ber of pits.____._f----__---Lining material Size: Diameter___ ___.____.____Depth_ y " __y_ <br /> Cesspool Distance from nearest well------------ Distance from foundation-------------_------Lining material- <br /> --------- <br /> ' . <br /> ❑ Size: Diameter-------------------------- -----------Depth_;------------- ---------------------------- --------Liquid Capacity------------------------ gals. <br /> • 144, S <br /> Privy-j is Distance from nearest well l ------------'------------------------------------ Distance from nearest building------------------------------------------- <br /> ❑ Distance to nearest lot line............ -- ------ --------------------------------- <br /> r <br /> .. ;,. <br /> V1 <br /> Remodeling and/or repairing (describe):--4//-- <br /> - -- �-- -----•-------------- --------------------------------------- <br /> ------------------------------------------------------9------------ ------ � �---------------------------------------------------- ------ -------------------------------------------------------------- <br /> e, - <br /> ---- --------------------•--------------------------------------------------- •----•-------------------- <br /> __ i~_ i, -----------•---------- <br /> - -----------------------------and rules and-r---•-- --------------------• >----------------------------- -----------...---------•-•----------------- <br /> I hereby certify that I have prepared this application and tha+ the work will be done in accordance with San Joaquin County <br /> ordinances, State la egulations of the San Joaquin Local Health District. <br /> i , <br /> 5i ned _ ! -------I------------------- Owner nd/,or Contractor) <br /> t 1e ---~ <br /> By: { --- ------------------------------------------------------ <br /> d <br /> (Plot plan, showi g size of lot,'location of system in relation to wells, buildings, etc., can be p d onireve a sid <br /> ► FOR DEPARTMENT USE ONLY v <br /> a <br /> APPLICATION ACC EPTED'BY------------ <br /> -------------- - ---- -- ------------------------:--:- :`-.- -__---_------:DATE----------- -- -- <br /> -�: <br /> REVIEWEDBY------------------------- - ------' = - -- -- ------------------------------------------------ DATE----------�-f------- --------•---- ------------- <br /> BUILDING PERMIT ISSUED = `- ---------- - DATE <br /> Alterationsand/or recommendations------ --- -•------------------------- -----------------•------ --------------------•---------••--••--- •--------------------•--•- -•-•----------•-----••------- <br /> ------------------------------------------- ------------------------------------------------•-------------•-•----------------------------------------------------------------------._...--- <br /> ---- ----------•------------•----------------------------------------- <br /> r k <br /> 4 , <br /> ----------•------- ----------------------------------------------------------------------------------- ---------------•---------- -----•-------------------- --- ••-- <br /> 1 � f�` <br /> FINAL -INSPECTION' BY:-- -----=------------ ---------------------- ------------- Date --------•------------- <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 />