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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 . <br /> P O BOX 2009, STOCKTON, CA 9520 RA YAf <br /> PERMIT EXPIRES Z YEAR FROM DATE ISSUED V,Fp <br /> (Complete in Triplicate) Sq OC Veit) <br /> 5 1992 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or ineta b�l}p��U9//yy Jj}� p�f <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and thE'if� �&Aw. This <br /> Joaquin County Public Health Services. §luk 4 San <br /> Job Address „�L H d 1 V1SjQJV <br /> City Lot Site/Acreage 1 Z 2 acre <br /> Owner's Name Arthur Wyatt Address 6290 Cheg�apeak e Ci rcl - PhoneX41 !rp!4E <br /> 951-1207 <br /> Contractor Soils Ex 1. Serudkae Benicia CA 94 ID <br /> TYPE OF WELL/PUMP: ense No. 582696�Phone707-451-92 3 <br /> NEW WELL ❑ WELL REPLACEMENT 17 <br /> DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK �` SEWER LINES 100 ft <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> PITS/SUMPS <br /> n Industrial p Open Bottom III Manteca Dia. of Well Excavation <br /> C}Domestic/Private -$ Dia. of Well Casing " <br /> til Gravel Pack n Tracy Type of Casing_ <br /> PVC i'1 Public 1-1 Other 171 Delta 5pecificatians <br /> Depth of Grout Seal - +�0 Type of Grout <br /> ! I Irrigation pprox. Depth I Eastern <br /> Surface Seai Installed by <br /> Repair Work Done L] Ty�o} Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material E Depth State Work Done 1 w <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION 11 (No Sept,c system permitted if public sewer "d <br /> is <br /> within 200 feet <br /> Installation will serve: Residence— Commercial_ Other available •1 <br /> r7- <br /> Number <br /> Number of living units: Number of bedrooms <br /> Character of Boit to a depth of 3 feet: �l <br /> SEPTIC TANK. O Type/Mfg Water table depth <br /> PKG. TREATMENT PLT, ❑ Capacity— No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines <br /> FILTER BED Total length/size <br /> C f Distance to nearest: Well Foundation_ <br /> Property Line <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPSCl DiNumber <br /> Distance to nearest. Well Foundation <br /> DISPOSAL PONDS p Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with S <br /> rules and regulations of the San Joaquin County an Joaquin county ordinances, state Laws, and 3 <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, <br /> tion laws of California " i ahall employ persons subject to workman's compsnaa <br /> The applicant ust Il for al re ired inspections. Complete drawing on reverse side. <br /> Signed X_ w <br /> Title: •L— <br /> Date: <br /> FOR DEPARTMENT SE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Dat l0' <br /> Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return a 1 copse t San JoaquinCounty P b is Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95241 G <br /> FEE AMOUNT DUE AMOUNT REMITTED ���✓ <br /> INFO CASH CEIVEp BY OAT•E <br /> �^ PERMIT'NO, <br /> • EM 14.26(REV.t i n ar y(�/ /4-g1 E)91 <br /> Em 14-26 VI.�J� `� <br />