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78-831
EnvironmentalHealth
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ACAMPO
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4200/4300 - Liquid Waste/Water Well Permits
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78-831
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Entry Properties
Last modified
6/15/2019 10:12:53 PM
Creation date
12/5/2017 5:10:56 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
78-831
PE
4211
STREET_NUMBER
22440
Direction
E
STREET_NAME
ACAMPO
STREET_TYPE
RD
City
ACAMPO
SITE_LOCATION
22440 E ACAMPO RD ACAMPO
RECEIVED_DATE
9/26/1978
P_LOCATION
TOM BARBERS
Supplemental fields
FilePath
\MIGRATIONS\A\ACAMPO\22440\78-831.PDF
QuestysFileName
78-831
QuestysRecordID
1629996
QuestysRecordType
12
Tags
EHD - Public
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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) Permit No.76--___3__/ <br /> r Date Issued__. � _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 and Regulations: <br /> JOB ADDRESS/LOCATION _ G= �C!- '�iL CENSUS TRACT - <br /> / ---- <br /> Owner's Name--- - ------ // A t----------e�� -L Zl� L ---- --- ------ -/-- - --- -----Phhoone-------------------------------------- <br /> Address - ----- ----City_ �/fZiP-j <br /> -- / <br /> y � - _________Contractor's Name License = Phone ._------ - -------- <br /> Installation will serve: Residence 0J Apartment House ❑ Commercial ❑ Trailer Court ❑ C <br /> r Motel ❑ Other----------------------------- ---------------- . <br /> Number of living units:-------!__------Number of bedrooms____. Garbage Grinder------------Lot Size----- _�`-t_`_-�` `_ , <br /> WaterSupply: Public System and name--------------- - ------------ ---------------------------------------------------------------------- - -- -- -----------------Private [� _ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ©' <br /> Hardpan ❑ 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK i/�� r <br /> [ Size ------- �� - Liquid Depth <br /> -- -- 'VCa acitY-A�C --------TYPe _-Material �_------No. Compartments------� ----------- ------------- <br /> l <br /> ------------------Foundation------1 ! U <br /> Distance to nearest: Well-------------- /- � _________Prop. Line_____________________. <br /> LEACHING LINE [,G'/ No. of Lines_________-�----------------Length of each line.-------- _______Total Length.--/----?-- <br /> Box._____-/----Type Filter Material--------- _ __Depth Filter Material--------/_1-�,________________________-__________---. <br /> i r ,f <br /> Distance�to nearest: Well___-____- �__�_-____Foundation_____/ _________._Property Line_______�______-_-_________--. <br /> e7-v / -y ,.� <br /> [' Depth----1_��-______Di�ameter----Z_//e �__.Number------------'h--------------- Rock Filled Yes [ No ❑ <br /> Water Table Depth f`et ------ Rock Size_l 1101- ------------------------- <br /> Distance to nearest: Well----____,/Ce--__-___--_--_____-_Foundation____ --------- Prop. Line____-_________________. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#____________________-__-__-__-__.__________.Date______________________----_---- ----__---) <br /> SepticTank (Specify Requirements)-------------------------- ---------------------------------------------------------------------------------------------------------------------------- <br /> DisposalField(Specify Requirements)--------------------- --------------------------------------------------------------------------------- ------ ---- - -------------- --------- <br /> ---------------------------------------------------------------------------------------------------:--------------------------------------------------------------------------------------------- ------------- <br /> ------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 subject to Workman's Compensation laws of California." <br /> Signed----------------------------------------- �� Owner <br /> f <br /> BY-- __- ---- ---- L-Z /%=11 1 �/�_! C '1 ------Title_-,_ <br /> - -------- --------- --------- ------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ? ------------------------------------------DATE_---- .r <br /> DIVISION OF LAND NUMBER - -------- -- --------------- - -- - -- ------------------------------------DATE- <br /> --------------�-- - <br /> ADDITIONAL COMMENTS-------------------- ------------------------------------------------ - - <br /> --------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- ---- ----------- ------------- <br /> --------------------------- <br /> ----------- <br /> - --- ------ -------------------------------------------------------------------------------------------- --------- -------------------------- <br /> - <br /> - C - <br /> ----------- <br /> ----- <br /> -------------------------------------------- <br /> --- <br /> Da -Final Inspection by: � - -------- ----- - - <br /> EH 13 24 SAN jOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />
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