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71-080
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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4200/4300 - Liquid Waste/Water Well Permits
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71-080
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Entry Properties
Last modified
2/21/2019 10:32:47 PM
Creation date
12/4/2017 10:54:17 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
71-080
STREET_NUMBER
22584
Direction
N
STREET_NAME
DUSTIN
STREET_TYPE
RD
SITE_LOCATION
22584 N DUSTIN RD
RECEIVED_DATE
2/5/1971
P_LOCATION
TERRY SCHWEIGERDT
Supplemental fields
FilePath
\MIGRATIONS\D\DUSTIN\22584\71-080.PDF
QuestysFileName
71-080
QuestysRecordID
1720445
QuestysRecordType
12
Tags
EHD - Public
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� FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT r/O � <br /> '= -../--------------- <br /> - -------------------------------------------------- <br /> (Complete in Triplicate) <br /> Permit No. <br /> ---------=----------------------------------------------- <br /> ------------ --- _____--------------- This Permit Expires 1 Year From Date Issued Date Issued -- r� -� <br /> _ - <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 it C ty Ordinance, No. 549 and existing Rules and Regulations: <br /> - CENSUS TRACT _ _ __.-_.- "-..JOB ADDRESS/LOCAT N - _� ----- - <br /> ------------ ------ - -- ------ - <br /> -.--- <br /> Owner's Name ----- -- ---------- - ---------:---------------- -------------Phone --------------- -------------------- <br /> Address - ..City - --------------------------------------- t <br /> d jG <br /> Contractor's Name -----..--. c rt �-- License #I�f - -- Phone -.---------------------------- <br /> Installation will serve; Residence partment House°❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number.of living units...-)------ Number of bedrooms-_--_--Garbage Grinder --.--------- Lot Size --------------------------------------- <br /> Water <br /> -------------------- ---Water Supply: Public System and name -------- -------------•------------------------- ----------------------------------------- --------------------Private <br /> Character of soil to a depth of 3 feet; Sand'[] Silt❑ Clay [I Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ -Adobe ❑ Fill Material ------------ If yes, type _ I <br /> (plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> 11: f )?, . <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> k <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ J _.-.�_.Size.. ----------------------------------------- Liquid Depth ---------------- --------- <br /> I , Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ..................... <br /> ii Distance to nearest: Well -----------------------------`------Foundation ---------------------- Prop. Line ----..---- .---------pp <br /> LEACHING LINE [ ] No. of Lines -----------------------r Length of each line---------------------------- Total Length -----------------------:---"s <br /> 'D' Box .-.--------_ Type Filter Material``___' .... ------- <br /> Depth Filter Material -------- ------------- Z <br /> i <br /> Distance to nearest: Well------- ----------------- Foundation ------------------------ Property Line ------------------ <br /> SEEPAGE PIT [ ] Depth ------------------- Diameter- -----------------Number ------------ ---�:______ Rock Filled Yes ❑ No 0"' <br /> Water Table Depth = Rock Size - ------ <br /> i <br /> Distance to nearest: Well':- ------------------------------------Foundation - -------------- Prop. Line _-___-..-_-_.-__.-_y, <br /> REPAIR,/ADDITION(Prev. Sanitation Permit# -------\l,ti----------------------- `Date ---_,;----------------------------) 1r. <br /> Septic Tank (Specify Requirements) ------ .---------- -----------`---- ----=-------- --------- ------------------ ---------••---------------------------3 <br /> Disposal Field (Specify Re uirements -z-• ----------------------------------------- ---------------�� -- <br /> -_- __-__ _'_______ '-- -- --__• - --"-- -- ______-__� - ----------------------- - <br /> ------------------------------------------------------- <br /> (Draw existingand required addition on reverse side) f <br /> 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' ompensation laws of California." <br /> Signed ---------------- ----------- -------------- - - ---- -------- - --- --------- Owner <br /> BY - ----------------------------------- le - <br /> --------- -------- -- - <br /> - ----------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY __ �- �Y -------------------------- -------------------------------- DATE -'-QST '. /-------------------- <br /> BUIL-DING PERMIT ISSUED --------------- -------------- -----------=--------------DATE --------------- --------------------------- r <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------- --- --------- ----------------------- ------------------------------ ----------------------- --- ------------ i <br /> ----- ------ -- ---------------------------------------------- ----------------------------------------------------------------------------------------------- --------------------------------- <br /> ------ -- ----------------- ------------------------------------------------------------------- --------------- - -- ------ <br /> Final Inspection by: -- � -_e.. %�------------------------ ---------------Date -'- - � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />
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