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SU0004587
EnvironmentalHealth
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2600 - Land Use Program
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PA-0300490
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SU0004587
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Entry Properties
Last modified
12/11/2019 5:03:03 PM
Creation date
9/6/2019 10:46:11 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0004587
PE
2633
FACILITY_NAME
PA-0300490
STREET_NUMBER
17390
Direction
N
STREET_NAME
KROLL
STREET_TYPE
RD
City
LODI
Zip
95240
APN
05115038
ENTERED_DATE
7/27/2004 12:00:00 AM
SITE_LOCATION
17390 N KROLL RD
RECEIVED_DATE
10/14/2003 12:00:00 AM
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\sballwahn
Supplemental fields
FilePath
\MIGRATIONS\K\KROLL\17390\PA-0300490\SU0004587\CORRESPOND.PDF
Tags
EHD - Public
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} FOR OFFICE USE: ,rte <br /> APPLICATION FOR SANITATION PC ...T <br /> ---------------- <br /> — <br /> (Complete in Triplicate) Permit No. <br /> 7 <br /> - <br /> -------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described, This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> <= <br /> "` . = f'� ' .....-- ---CENSUS TRACT ---- ------ <br /> JOB. ADDRESS/LOCATION `"i . -- .-= -•_-_-_ -' _ - -------------- <br /> Owner's -- ----------- -----------... ------------------------------------Phone <br /> Address _sj_ c _�.�� }! --------------------------- --•---- <br /> Contractor's Name ---a.:• = .............' '' ...... License # l '. __d'_Y__ Phone - ---------- -------- <br /> Installation will serve: Residence ❑ Apartment House-0 Commercial ❑Trailer Court 0 <br /> Motel ❑ Other --------------------- ------------------ <br /> Number of living units_____________ Number of bedrooms ._.._.______Garbage Grinder ............ Lot Size ---------------.----------------............ V <br /> Water Supply: Public System and name ----------------------------------•------------------3----------------•----------------------------•---------.Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam [r Clay Loam ❑ <br /> Hardpan ❑ Adobe 0 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 204 feet) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ---------------------.--. <br /> Capacity - --- ---- -- Type ---------------- --- Material- ------------- ------ No. Compartments -•---- <br /> jDistance 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 /> SEEPAGE PIT [ ) Depth -- ------ Diameter ________________ Number --------- ------ Rock Filled Yes ❑ No C] <br /> Water Table Depth ------------------------------------ -----------Rock Size ----- ------------.-.._..----- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------- Prop. Line -------------- ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------.------------------) . <br /> Septic Tank {Specify Requirements) ------------------- ---- ------ --------- - ---- ----------------- --`-------------------------- -----•------ -------------------- <br /> �•-- <br /> Disposal Field (Specify Requirements) ----- � _:: = A --------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------- <br /> .................................................. _ ...._..___._.____._.____.--.___.._______. _._--..__ <br /> (Draw existing and required addition on reverse side) <br /> y I 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 employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .... y_ <br /> 9 u Owner <br /> f <br /> B .. (If other than owner) �-- � � '--\'=--- ._ 1..tC C.�1 J��., -:<<�+ �.._C:'1.--------------------------------- <br /> Y -..._.._. �--Title ...... <br /> FOR DEPARTMENT USE ONLY <br /> df <br /> APPLICATION ACCEPTED BY :-::�' . - -- - --------------------- ------- ------.... DATE . ; '" <br /> BUILDING PERMIT ISSUED ----------- ---- -- --DATE ------------- ----------------------7-- <br /> ADDITIONAL COMMENTS ------------ - --...------------------------=------------------ - - .._ <br /> ----- ---------------------------------------------------------------- -------- <br /> - ` <br /> Final Inspection by: . ------------------ ------------ --------------------------------------Date ... ....... \ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E- H. 9 1-'68 Rev. 5M <br />
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