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72-252
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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72-252
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Last modified
3/5/2019 2:41:26 AM
Creation date
12/5/2017 1:15:33 AM
Metadata
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Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
STREET_NUMBER
0
Direction
S
STREET_NAME
ENDOW
STREET_TYPE
RD
City
FRENCH CAMP
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FilePath
\MIGRATIONS\E\ENDOW\0\72-252.PDF
QuestysRecordID
0
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EHD - Public
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FOR OFFICE USE: _____� - " <br /> ----- ---------------------------- <br /> --------- APPLICATION FOR SAN'iTATION PERMIT <br /> `' (Complete lete in T. ' rate) Permit No: <br /> I. <br /> This Permit Expires ] t ram Date issued Date Issued - `------------- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: :Y <br /> JOB ADDRESSAOCATION 1- -_ �c�� sit« ( <br /> I ----------6------------- -- <br /> -�ISUS TRACT <br /> Owner's Name --����---- ---------- ---•----------- <br /> ----Phone ----- <br /> --- -:/-��-�----------- ------------ City ---- r? --------------- <br /> Contractor's <br /> 3 <br /> Name / -l1 r`a --------- --r--------- - <br /> - ----- -------License #r��l--�-�--- - Phone���_�___ <br /> installation will serve: Residence �rtment House[D Commercial :[]Trailer Court ;Q <br /> Motel Q Other <br /> Number of living units------- -_- Number of bedrooms'-_?......Garbage GrinderLot Size -- _--_--_-__-- _-- <br /> Water Supply: Public System and name --_-_- --------- <br /> -----------------------------------------------' <br /> ' Private <br /> - ------------------------------- -- ------------------ <br /> Character of soil to a depth of 3 feet: � Sand' Silt <br /> t i Q Q� Gay Peat❑ Sandy Loam •Q Clay Loam; <br /> $ _Hardpan Q Adobe FffFill Material _ Q If yes, type -------------------_-----_ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,g , etc. must be placedon reverse side.) <br /> NEW INSTALLATION.- (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ 1 SEPTIC TANK [ V <br /> i j �� Size---- �,?CS c �� <br /> ' - CVL�--�------- --- LiquidDepth - ��--•------•--Capacity _A " = '--_ T `^C /J �.Ype ° � -� Mater ia _z�_c Compartments Z-- <br /> Distance to nearest: Well ------- _----__Foundation -__2Q_�-_-__ <br /> g �O --- Pro Line - <br /> LEACHING LINE � r' r p• ---•-•'----.---••-- ' b <br /> [ No. of Lines _; ----_--__ Length of each line-- C� J <br /> _ - Total Lert�le _0_.---------•---- <br /> D' Box ,y- TypeFilter Material --------Depth Filter Material ._-1-------------- -- <br /> Distance to neatestr ------------ Foundation ,a-_�-----.----- Property Line �� <br /> - <br /> SEEPAGE PIT <br /> r � -..----- - <br /> ( ] Depth ---------------_--" Diameter ---------------- Number ---------------------------- Rock Filled Yes Q No 0 Water Table Depth __-_--_--___� ' <br /> ---------_--.:------------•---- __Rock Size <br /> Distance to nearest: Well -____---__--------- -------^�.-- ---Foundation --------------- <br /> r .---- Prop. Line -------------- - <br /> REPAiR/ADDITION(Prev. Sanitation Permit# --------------------------------- <br /> Date <br /> --------------- <br /> Septic Tank (Specify Requirements) ----- ------------ - <br /> Disposal Field (Specify <br /> f--r Requirements) -----_---_---_ <br /> -_--_- .i ---------------- - --- ----------1--�-- <br /> ----v- <br /> --- -------------------•--------------- <br /> -------------- <br /> -- ---_-----'- ---- <br /> ------------ <br /> ----------------- . - --_. <br /> ___ -------- - --------- __ <br /> -------------------------- --- ---------------------------------------------------•--_--------------- --------------- ___________ _ <br /> _ (Draw existing and required addition on reverse side) <br /> ! hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and-Regulations of the San Joaquin'Local-Health District: Home owner or licen- <br /> sed agents signature.certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not eFn to 4an <br /> as to become subject to Workman's Compensation laws of California." p Y Y Person in such manner <br /> Signed-_-:.:.. ! ; I.—.- j <br /> ----------------- - Owner <br /> r <br /> BY ---------- ------- - ------ --- ---(Ji--k-k-i = ----------- Title --- �„ I r} <br /> -¢ <br /> (If o#her than ow 'e } ' ---'------------- --- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __-- _-----____-_ <br /> BUILDING PERMIT ISSUED DATE 3�Jy' 7 f <br /> ADDITIONAL COMMENTS ----------- ----------------------------------------------------------- -----------DATE --------=---- ----- <br /> ----- - ------ ----- --- <br /> Final Inspection-by: -----T _ ----------- ----------------------------- -- 1 <br /> = �' <br /> �{ ��� <br /> -------------------------------Date ... <br /> - �7�'---------- ---------- --- <br /> s SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> E. H. 9 1-'b8 Rev, 5M i <br />
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