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79-401
EnvironmentalHealth
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CLEMENTS
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4200/4300 - Liquid Waste/Water Well Permits
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79-401
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Last modified
6/23/2019 10:50:11 PM
Creation date
12/4/2017 6:34:33 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
79-401
STREET_NUMBER
10122
Direction
N
STREET_NAME
CLEMENTS
STREET_TYPE
RD
City
STOCKTON
SITE_LOCATION
10122 N CLEMENTS RD
RECEIVED_DATE
05/16/1979
P_LOCATION
PETE MARIANI
Supplemental fields
FilePath
\MIGRATIONS\C\CLEMENTS\10122\79-401.PDF
QuestysFileName
79-401
QuestysRecordID
1692849
QuestysRecordType
12
Tags
EHD - Public
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FOR OFFICE USE:�----yy- .' FOR OFFICE SEA�A'PPLICATION FOR SANITATION PERMIT.............. ................... ........... c l✓,` Permit No.. �� <br /> (Complete in Triplicate) _ l <br /> Date Issued__.1 J-.6._ <br /> ............................... ...... This Permit Expires 1 Year From Date Issued <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 and existing Rules an I Re tions <br /> JOB ADDRESS/LOC TION..14. _ .-../G�....... _.. a CENSUS TRACT........... . ................ <br /> Owner's Name �P. ...`f .. .. .. ... ... . ,. .... ... . - Phone... <br /> Address....-- , -- ----- ....City. - ----- --------- ----- ......... ..Zip--.: --,-__--- --_-------- <br /> Contractor's <br /> --. <br /> Contractor's Name.............. ..---license # Ph ane_` <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other .................... ........................ <br /> Number of living units:..... .......Number of bedrooms._,52-Garbage Grinder------------Lot Size---..-.-- ..... . ---- ............... .. <br /> Water Supply: Public System and name....................... ------------------------------------------- - ----------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ . Clciy ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpon W Adobe ❑ Fill Material.- .... .°- If yes, type----_-•---------_--- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) e— <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ..........:............. .----------------- <br /> ----Liquid Depth-------------- <br /> ..-... i <br /> - <br /> Capacity- ---- -- ----------TYPe--------- ...... ...._ Material------------ ---------No. Compartments .......................... <br /> Distance to nearest: Well---------- ----------------- ---- ---------Foundation ....... . ......... ..-Prop. Line........- --.....---------- <br /> LEACHING LINE [ } No. of.,Lines ...----------------------- Length of each line------------------------- -- Total Length .. ..................--............... <br /> 'D' Box-----.- Type Filter Material_..... Depth Filter Material.-.-------- ------------ -- -------- _-------- <br /> Distance•to nearest: Well............................Foundation---------------------- ---..Property Line---------......---_.....- ...-... , <br /> _ - � t <br /> SEEPAGE PIT [ ] Depth._ ..........Diameter--------------------Number...------`-------._....------- Rock Filled Yes❑ No❑ <br /> WaterTable Depth. • •............................ -.....-------::::.---Rock-Size-.....-... :_,_..... .. -----------....- <br /> Distance to nearest: Well-------------------------------------------Foundation.-----....................Prop. Line-.------.---.-. -------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------=------------- ----------Date-....................------------ ............ <br /> ) <br /> i <br /> Septic Tank (Specify Requirements►-_-. _._- - . "` ` "` _ <br /> �... --------- ; r. <br /> Dis osal Field (Specify Requirements)_ <br /> Ave <br /> L� .. '. <br /> ............. ----- ----- <br /> "jDraw existing and required addition-on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work-for-which this permit is issued, I shall not employ any person in such manner as <br /> to become subje Wark'ma Compensation laws of California." 1 <br /> � . i <br /> Signed------. t .. ----.---- Owner <br /> • � I <br /> 1, By---------- ------- ------------............... Title. /... <br /> (If other than owner) <br /> EPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY _ ------------- -- -DATE . (ar- ... _. ..----------- <br /> DIVISION OF LAND NUMBER....... ... --------,DATE----- - -------- -------. <br /> ADDITIONAL COMMENTS-....--............. .. ---- ---- -.--- - - --- ... ..... <br /> ----------- ---------------------------------- -------------------- - --------------------------- ... - -------------- -- ------------..........,..--------- ------------ --- ....------ --- -------- <br /> A <br /> Final-lnspecfion by:......... ... <br /> Dat --- <br /> EH 13 24 SAN JOAQUIN CAL HEALTH DISTRICT ras 21677 Rev. 7/.7s 3M y� <br />
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