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72-1178
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4200/4300 - Liquid Waste/Water Well Permits
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72-1178
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Last modified
3/2/2019 10:54:59 PM
Creation date
12/1/2017 9:04:01 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
72-1178
STREET_NAME
SHELTON
STREET_TYPE
RD
RECEIVED_DATE
12/29/1972
P_LOCATION
DOROTHY CADY
Supplemental fields
FilePath
\MIGRATIONS\S\SHELTON\0\72-1178.PDF
QuestysFileName
72-1178
QuestysRecordID
1923221
QuestysRecordType
12
Tags
EHD - Public
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FOR OFFICE USE- <br /> APPLICATION OOR SANITATION PERMIT <br /> ____ _ ,-__.7 l <br /> (Complete in Triplicate) Permit No.7 <br /> Date Issued <br /> _--_----_---- This Permit Expires 1 Year From Date Issued <br /> Appl-i'cation 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 No549 and existing Rules and Regulations:. <br /> R& <br /> /I&(art�&i�a's:ta f - Q /---Wy-af- ----.-CENSUS TRACT ------------------------- <br /> JOB ADDRESS/LOCATION a E7- <br /> .Fnddq <br /> Owner's Name a�^ 6,.y dad - --- Phone <br /> ✓�`j' <br /> _., ' -Q� JC----,:L.�L7----- --------------------------------------- C'ttY ---- Gi -l---�r +lr/ti------------------------------- <br /> i - - <br /> A <br /> ac l License # --------- Phone <br /> Contractor's <br /> tor's Name -------- --------P -e-r------------------------------------- --- <br /> Installation will serve: Residence p Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ---------- <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size -------------------- <br /> i. Water Supply: Public System and name- --------------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand A] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe-❑ Fill Material - ---------- If yes, type <br /> e (Plot plan, showing size of lot, ,Iocation 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 /> t <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] ------------------ Liquid Depth ---!` ----------,..... . <br /> Capacity _/tea-f-------- Type pie:-( t- Material-_ Qcvc-i; No. Compartments -_ =..-- <br /> Distance 'to nearest: Well -----/.. D-_e-----------------_Founda#ion ---tQ-------------- Prop. Lin _s__-____:-_-_-- <br /> LEACHING LINE [ ] No. of Lines --------/------------ Length of each line------------- ------ Total Length ----------_--- <br /> 'D' Box .1---------- Type Filter Material A4_GJ--C---------Depth Filter Material -----_/-Q`,-----_----_- <br /> i <br /> Distance to nearest: Well -----l_-+` -�'t7_ Foundation -------- Property Property Line <br /> t SEEPAGE PIT Depth -_ Rock Filled Yes No <br /> [ � p --=------------- Diameter ---------------. Number .--------------- - ----- - ❑ <br /> � <br /> r Water To I ble Depth ----- ------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------_------------ <br /> } <br /> REPAIR/ADDITION(Prev. Sanitation Permit F# -------- ----------------------------------- Date ----------------------------------1 <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- f---------------------------- <br /> FDisposal Field (Specify Requirements) -------- - ------------------------------------------------------------------------------------------------------- -------------- <br /> ------- ----------------------------------------------------------=------------------------ <br /> r <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 <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 beco bj to or an'Comp nsation aws of California." <br /> r Signed <br /> - - - -- --- - - =--------------------------- Owner <br /> BY ---------- - --- ----------------- -----7------------------------------- Title ---------------- ----- --------- ---------------------------- ---------- <br /> ti€� nerM <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------ --`=-------- ---- ------------ ----------------------- ------------- DATE 1 7-2r <br /> ' BUILDING PERMIT ISSUED --------- ---- ------------------------------------------------------------ ------------------------------DATE ------------- ----------------------------- <br /> ADDITIONAL COMMENTS --------------- ---------------------- --------------------------- <br /> . �' ' -- ---------------------------- <br /> ----------�-----------� <br /> � . �" 0.. -------------------- <br /> A.0 <br /> ----------- ��= � ----------------- ------------------------------ a <br /> Final Inspection by: ---- --------Date ----�l- - ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />
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