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72-201
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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72-201
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Entry Properties
Last modified
3/3/2019 11:12:37 PM
Creation date
12/2/2017 7:12:42 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
72-201
FACILITY_NAME
SAN JOAQUIN RIVER CLUB
STREET_NUMBER
30000
STREET_NAME
KASSON
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
LOT 204
Supplemental fields
FilePath
\MIGRATIONS\K\KASSON\30000\UNKNOWN STREET\72-201.PDF
QuestysRecordID
0
Tags
EHD - Public
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FOR OFFICE USE: <br /> -------------------;-------------------------------------- APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> (Complete in Triplicate) <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 permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance ?149 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ___ --------j ,,7`03,l6C�/Y_-b� _&�4 ENSUS TRACT .________________________ <br /> Owner's Name <br /> --------- ` .. ------------------------Phone <br /> _-___ / ___,�c'_ ,a�- <br /> Address ---------� �� - - ---��„ � Ems/ ' --------------------------------------------- City ------ --------------------- ---- <br /> Contractor's Name ----- _-_----_ -_________-License # ----- Phone '-- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ----------------------------------------- <br /> Number of living units:__!______ Number of bedrooms ----I......Garbage Grinder _/ _a_ Lot Size _�K '' __��_p..-____.-_______- <br /> Water Supply: Public System and name --------------------------- ---------------- -----------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam V <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:V ;;t Size____ .,,.%r_Z5._1.'_�'�---___.____ Liquid Depth -_- --------------- 1 <br /> Capacity � _ Type Material_MVICY nn�%a. Compartments 473---------------- d <br /> Distance to nearest: Well --- _-----_- ------------------------Foundation __ _.io-_______ Prop. Line -__- <br /> LEACHING LINE j] No. of Lines __f------------------ Length of each line_-f_p ___________ Total Length -----4 LAG?.._...._.._ <br /> 'D' Box ( --- Type Filter Material _,t�(� , ____Depth Filter Material —,11,9111---------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ----`_2____-______ Property Line .....�................ <br /> SEEPAGE PIT [ ] Depth __________________ Diameter ---------------- Number ______ -------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ---------------------•---.------ d <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------------•--------------•-•----------- <br /> Disposal Field (Specify Requirements) ____________ ______________ <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 Joaquin d <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or liven-c7 <br /> sed agents signature certifies the following: <br /> "I certify that in the p rformance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become sublesf o Work a Is Com cation laws of California ` <br /> Signed --------- ---- � ---------- --- - <br /> ---'`- - -----,-- -------------------- ------ <br /> Owner <br /> By -- ---- ------ --- ----- -------------- ------------------------ Title ---------------- -------------- ----------------------- ------------ <br /> other owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- --- - -------- -------------------------------------------------------------------------- DATE -- - s -��c1'--------------- <br /> BUILDING PERMIT ISSUED ---- --------------------- ------------------- -------------DATE ---------------------------- - <br /> ADDITIONALCOMMENTS ----------------- ---------•------------------------------------- -----------------------------------------------------------------=-------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- ------, ------------------------------------------------------------------- ------------------------------------------------------ ------------------------ <br /> --------------------------------- ---- --- <br /> ----------------------------------------------------- -- -------------------------------------------- <br /> Final <br /> - ----- ----- - ----------------------- - <br /> FinalInspection by: -- -------- ---------------------------------------------------------------------------------------------Date ---�-----d�----------------------•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M C' <br />
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