91-1603 - Laserfiche WebLink

Home Browse Search

✓ `!- - - _„'�_-.._ .- - T. �-...� -� �_�^-vim+.y APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION k P O BOX 2009, STOCKTON, CA 95201 1 (209) 468-3447 R (Complete in Triplicate) Application is hereby siade,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ceapliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _ 6584 N. Waverly Road _ -_ city Linden Lot Site/Acreage 800 Owner'shlame Co. Of_ San Joaquin Address P_0_ BOX 1810 _Stkn ,CA Phone - '�LSEI rr Contrartor 0;11 Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER C Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r' industrial ❑ Open Bottom ❑ Manteca Na. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M P)Iblic CI Other ❑ Delta Depth of Grout Seal Type of Grout CJ IrriUation .— Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Welt Diameter Sealing Material i Depth Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW iNSTALLATION REPAIR/ADDITION 0 DESTRUCTION M (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence x Commercial— Other Number of living units: I Number of bedrooms 3 Character of soil to a depth of 3 feet: 5ilt/Clay Water table depth 100 SEPTIC TANK Type/Mfg P & L Capacity 1500 No. Compartments , PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well 600 ' Foundation 50 Property Line 2200 ' LEACHING LINE IN No. & Length of lines 3 _ 90 ' ,_ ,,,_,,,,- Total length/size 270 ' 4 n I FILTER BED n Distance to nearest: Well�Qr Foundation _ -7 Q— Property Line r SEEPAGE PITS 11 Depth Size Number - SUMPS L) Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not + employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re uired inspections. Complete drawing on reverse side. i woo ill Title: �, 1 Date: - 0 �PARTMENTE ONLY j Application Accepted by Data _��_ Area + Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2409, STOCKTON, CA 98201 INFa OUNT DUE AMOUNT REMITTED ��CKif /A�SH RECEIV'lEJ1D SY T -3 -91 r� DATE Q PERM17'NO. . EH 13-241REV.tins) ,f l�"� 1 ��.K.J � J� C'L I ' -3 - t I 19(463 t:M^,42e V