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71-1185
EnvironmentalHealth
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23471
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4200/4300 - Liquid Waste/Water Well Permits
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71-1185
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Entry Properties
Last modified
2/23/2019 11:16:01 PM
Creation date
12/1/2017 6:32:10 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
71-1185
STREET_NUMBER
23471
Direction
N
STREET_NAME
RAY
STREET_TYPE
RD
City
LODI
SITE_LOCATION
23471 N RAY RD
RECEIVED_DATE
12/27/71
P_LOCATION
RONALD BORTH
Supplemental fields
FilePath
\MIGRATIONS\R\RAY\23471\71-1185.PDF
QuestysFileName
71-1185
QuestysRecordID
1905575
QuestysRecordType
12
Tags
EHD - Public
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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <br /> ---------I---------------------------------------------- <br /> -------------------- ------------------------------------ .This Permit Expires 1 Year From Date Issued Date Issued _--_Z: ---- ---- <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 a existing Rules and Regulations: <br /> �J J <br /> JOB ADDRESS/LOCATION .f ,2__�jV/- _//_---- /r---- '- ---/-- -- ham ,f---)CENSUS TRACT -------------------------- <br /> Owner's Name ._ / _ l---fes --- ,�� / -------•------------------- -------Phone -------------------------------.---- <br /> Address �,� =--------------- -----------------.-- ----------- -----------. City <br /> f <br /> Contractor's Name .__/ __��v ______________________License #a,� / Xhones ,c5r���` <br /> Installation will serve: Residence Y.Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑ Other ----- -------------------------------------- <br /> Number of living units:__-- -___ Number of bedrooms.,------Garbage Grinder t Size _ _ ��_ <br /> Water Supply: Public System and name ----- =.-------------- ------------------------------------------------- ------------------------------------Private <br /> 1-1,, *tr* <br /> Character of soil to a depth of 3 feet: Sand i'D., Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑. dobe!❑ Fill Material -- -------- If yes, type _________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must4be 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 f ] � S'ze----------------------------------------------- Liquid Depth -------- ...... <br /> Capacity --------------------- Type _____ -`----------OMaterial---------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well <br /> ------ __-_Foundation ---------------------- Prop. Line -_----_-..._-___-__ <br /> - <br /> LEACHING_ LINE [ ] No. of Lines ___________________ ___ Length,fof each line---------------------------- Total Length _____-____ <br /> u_ ---------------------_,I <br /> ------ Type Filter Mat.rialepth Filter,Material --------------------------- ----------------_:�'�x <br /> ------------- Foundation <br /> ----------- Property Line ------------------------ <br /> Distance to nearest. Well ____________ <br /> SEEPAGE PIT [ �) Depth <br /> _ # ___ ____________________ Rock Filled Yes ❑ No ❑ i <br /> j9 Water Table Depth ------------------- -------------�-------------Rock Size __ <br /> " 1 <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ..--.------.--._.----. <br /> -+� . � ii r <br /> REPAIR/ADDITION(Prev. Sanitation Permit# __ _____. ` "-__4__________ Date _____-__-_________ ) <br /> _._.s.�... ` 0 r <br /> Septic Tank (Specify Requirements) ----- l = ------------ -----------'" i <br /> Disposal Field (Specify Requirements) ___ _ ___�'" "" �'" �• -- -- -.____ -_-----_- <br /> ,, -l � ----- ------------------------ <br /> ------------------V---p---c- 1----------------- ""� ------------------------ --------- - ---------------------------------------------- <br /> (Draw existing and required—.addition on reverse side) <br /> I hereby certify that I have prepared this application and thatithe 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 employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------ ----- - - - ----------------------- - _- Owner,=ca <br /> r v ------- Title d <br /> ther than owner) <br /> 1 FOR DEPARTMENT USE ONLY"' AI <br /> APPLICATION ACCEPTED BY -----y----- --`--------- ------------------------------------------------------1------------- DATE J-2- P-77BUILDING PERMIT 'ISSUED - --------------DATE ------------------•------------------------ <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------- ----------------------------- ----------- <br /> -------------- ------------------------------------------- <br /> ---------------- -----' ---------------------------------------------------------------------------- -----------------•- ------ ------ <br /> �' ---- -- ----------------------------------------------------- ---------------------------- <br /> ---- ---- <br /> Final Inspection by: �I �,..P -------- ------------------------------------------- ------- -----------------.Date ---�_ �_ _• '. . <br /> G" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1 x'68 Rev. 5M. ` '` i` *� •� <br />
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