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77-352 (2)
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4200/4300 - Liquid Waste/Water Well Permits
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77-352 (2)
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Entry Properties
Last modified
5/24/2019 10:06:59 PM
Creation date
12/2/2017 6:56:11 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
77-352
PE
4210
STREET_NUMBER
1B001
STREET_NAME
EVERGREEN
City
TRACY
SITE_LOCATION
30000 KASSON RD - 1B001 EVERGREEN
RECEIVED_DATE
4/28/1977
P_LOCATION
FRED JENSEN
Supplemental fields
FilePath
\MIGRATIONS\K\KASSON\30000\EVERGREEN\1B001\77-352.PDF
QuestysRecordID
1802950
Tags
EHD - Public
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FOR OFFICE USE: 1 d oo I v�.� Lj��� <br /> APPLICATION FOR-SANITATION PERMIT <br /> C....................'.............................. (Complete in Triplicate! Permit No. 2. : .�'" <br /> ......................................................... This Permit Expires 1 Year From Dob Issued <br /> Date issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heroin <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulotionsc <br /> JOB ADDRESS/LOCATION .......... ... -.�_ <br /> ` -� 'f d--l3 s' R,Q,........................ .1 <br /> Owner's Name '.' 0-- . ...._.... Phone ------------------------------------ <br /> .-J.. <br /> Address .......t 5l9 ----- <br /> City <br /> Contractor's Name ........... � ®_ <br /> License# . �1 fJ.. ..._ <br /> Installation will serve: Residence partment House❑ Commercial❑Trailer Court ❑ <br /> Motel0 Other............................................ <br /> Number of living units:............ Number of bedrooms ----;„.._.Garbage Grinder ............ Lot Size ... h.............. <br /> Water Supply: Public System and name .......sVTR-C''s----............................_-....... ......................•......._ .........Private <br /> Character of soil to a depth of 3 feat: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loam�y Loam❑ <br /> Hardpan❑ Adobe❑ Fill Materlol ............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 f ] Size...............•................................ Liquid Depth ................... <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 ._.�PQ.�-° '..Depth filter Material . ................: <br /> Distance to nearest: Well .......... Foundation ........................ Property Line <br /> .. ............ . <br /> SEEPAGE PIT <br /> E I Depth .................... Diameter ................ Number ............................ Rods Filled Yes Ems❑ c� <br /> Water Table Depth .. <br /> --------------------------------•--•--••---...Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......... .. ---•... ................. Date ..................................I <br /> Septic Tank (Specify Requirements) ... ...... ............ .............................................................. <br /> Disposal Field (Specify Requirements) ...................... .............................................................................................................. <br /> ....................................................---- -------•----------•--•----••----------•----..............................-•---................................................_.........I._..... <br /> •-•-------------•----------- ---------- ------.------------ ---------------------------- ......---..........-............................................................................................ <br /> (Draw 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 Jm qwn <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heallh District. Horne owner or Ikon- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit Is Issued, 1 shall not employ any person lin such manner <br /> as to beco subject to W rkman's Compensation laws of California." <br /> Signed ......... .. . . ......................................... Owner <br /> BY ---- .. . ---- _ +SL`s"'----------- - .---------- Title . ............._.._. ............_...- ----- .................... <br /> (if o r than owner) <br /> FOR DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY . ...... ..................... . DATE .. .-�i2. ........ <br /> BUILDING PERMIT ISSUED DATE . ............................................ <br /> ADDITIONAL COMMENTS --- ------_... ....................... _ ._...._......._.. - <br /> - --------------_-- ------------- ------------------------ . -•------...-------•----........................... <br /> ----- .......... _.. --- -----------------•--•-._._............. <br /> ........ ............. <br /> .. -- - -- ---- ------- <br /> Final Inspection- <br /> ns ection b . _.----Dat1pve .. .. ....._. �- .. <br /> EH 13 2).i 1-613 v. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />
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