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15106
EnvironmentalHealth
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CLARK
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4200/4300 - Liquid Waste/Water Well Permits
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15106
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Entry Properties
Last modified
11/28/2018 10:09:57 PM
Creation date
12/4/2017 6:27:12 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
15106
STREET_NUMBER
3624
STREET_NAME
CLARK
STREET_TYPE
DR
City
STOCKTON
SITE_LOCATION
3624 CLARK DR
RECEIVED_DATE
12/03/1962
P_LOCATION
ROY FORSYTH
Supplemental fields
FilePath
\MIGRATIONS\C\CLARK\3624\15106.PDF
QuestysFileName
15106
QuestysRecordID
1691654
QuestysRecordType
12
Tags
EHD - Public
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FOR OFFICE USE. <br /> -------------------- Permit No. 6) <br />----------- APPLICATION FOR SANITATION PERMIT <br />------------------ --- --------------- (Complete in Duplicate) Date issued ...... <br /> ----------------- ----------- This Permit Expires I Year From Date Issued <br /> -------------- -------------------------------------- <br /> Application 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 compliance with County Ordinance No. 549. <br /> ;z (V� ------------------------------------------------------------------------------------------------------ <br /> .V JOB ADDRESS LOCATION__________________--------------- <br /> ° ---- Phone_---------------------------------- <br /> Owner's Name__':_/_W--- .- - - ------------------------------------------------------ ------------------------ <br /> Address------ ..... -------------------I.,-------------------------------------------------- <br /> ... Phone--------------------------------- <br /> Contractor's Name ----- •-------- House C] Commercial 0 Trailer Court (3 Motel 0 Other 0 <br /> Installation will serve: Residepce Ap�.rtmenf H 72 <br /> ze ------------_-- <br /> ------------ <br /> Number of living units. Ur ofbedrooms __:� Number of baths Lot si <br /> Water Supply: Public system F] Community system El Private �epth TO Wafer Table I-Lit. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F1 Sandy Loam El Clay Loam-0- Clay [] Adobe(21-14ardpan C1 <br /> Previous Application Made: (if yes,dote____________________) No New Construction: Yes [El"No E3 FHA/VA.. Yes E] ,No � <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> It <br /> Sept' Tan Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------ <br /> No. of compartments---------------- ---------Size—-----------------------Uquid clepth--------------------------Capacity---------------------- <br /> from foundation.___.__.__:____---_.Distance Distance to nearest lot line___..___--____... <br /> ------- <br /> Dis sal Fj Distance from nearest well-----------------Distance ---------- -.Width of trench----------------------------------- <br /> Number of lines----•------------------------------Length of each line---------------------------- <br /> length_--------------------------------------- <br /> Type of filter material_----_------I---------Depth of filter material-----------------------Total f —0 <br /> Distance to nearest well-Po-------------Distanc�--Size: <br /> d ion__,m?J.------._Distance to nearest lot line-0. ......... <br /> , at <br /> r___J45; "._.Depth------g�!_ <br /> Seeps it: Diamete - ------- ................. <br /> lk Number of plifs;-----/--------------Lining material- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining maferia ------ <br /> 0 Size: Diameter--------------------------- ----------Depth----------------------------------------------------Li quid Capacity---------------------- <br /> Privy: Distance from nearest well____-.-_______________________ from nearest building-------------------•-----------•---------- <br /> ❑ Distance to nearest lot line--------- ---------------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe)___________________--------------------------------------------------------------------------------------------------- <br /> -------------I...---------------------------------------------------------------------------------------------------------------------------------- ------------- --------- ---------------------------------------------- <br /> -------------------------------------------------------------- ----------------------------------------------------------------- ---------------------------------I-------------------- ---------11---------I...... <br /> ----------- ------------ <br /> -----------------------------------------------•------•--------•--------------------------------------•-- County <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> ------------------jOwner and/or Contractor) <br /> (Signed)---------------------------------------------- ----------------------- ----------------------- -------------------------------------------------- <br /> By---------------------------------------------------------- --------------------------------------------------------------------- (Title)---------------------------------------- --- --- ---- --------- <br /> Iplot 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 /> APPLICATION ACCEPTED BY_-- --- ------- -------- - ------------------- -------------------------------------- <br /> -- <br /> - <br /> -------------------------------------------------------------- <br /> REVIEWED BY ---------- -_------ DATE-- <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------- DATE-----------_------------------------------------------------------------------------------------- <br /> - <br /> Alterations and/or recommendations:------------------------------------------------- ------------------------------------------------------------------- <br /> ----- ---- ---------- <br /> ---------------- -------------- -S- -------------------------- <br /> ---------- ----- -------- ---------- <br /> -- ----------- '11�k_ ( — <br /> ----1. ----------------- --------- ----------------------- ----------------------------------- ----------- ------------ <br /> ------Z -------------- ——--------i_� ---------------------- <br /> ------- ------ ---------------------------------------------- <br /> -- --------------------------------------I----------- --------------------------------------------------------------- .................... <br /> R kz.------4 <br /> . _��--- ---------------------------------------- <br /> -------- ------------------------ -----I- <br /> ------------------------I- --------I-- ----------------------------------------------------------------- -------------- --.(?.-72------------------_--- <br /> - p, <br /> FINAL INSPECTION BY:.____-..._.--- <br /> Date-----—----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lovil,California Manteca,California Tracy,California <br /> ES 9 REVISED 8_59 2M 5-62 ATLAS <br />
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