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APPLICATION SAN JOAQUIN COUNTY; PUBLIC-HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ; C 1` PERMIT EXPIRES 1 YEAR -FROM DATE ISSUED (Complete in Triplicate) Sq' OCT I S �gg2 Ii' PU JOAO tj r1r� Application is hereby made to San Joaquin`County for a permit to construct and/or insta0&4 hw it atl MAa . This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 am-Ne'''11 E i�.W�e�sf San Joaquin County Public Health Services. , " LTH DIVISfaN Job AddressCity Lot Size/Acreage 1/2 acre 4511 PcL,-;±f±u AveOwner's Name Arthur_ Wyatt_ __- __ Address 6290 Chesapeak e Circles Phone 51-1207 m M41 SPR _ Contractor_ Soils Emol. Se- dvifae Benicia ,_ CA -3±22-License No. x582696 Phone7 0 7-4 5 1-9 2 L 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service welz ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES 100 it 'DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R" Dia. of Wait Casing "J " 5t Domestic/Private 0 Gravel Pack ❑ Tracy + Type of Casing_ PVJ_ Specifications I'I Public 1-1 Other ,; n Delta Depth of Grout Seat 40 Type of.Grout AnrtI anti w I I Irrigation -4-OApprox. Depth ().J Eastern Surface Saul Installed by + Repair Work Done 0 Ty'4e'gf Pump H.P.' State Work Dane Loh W Well Destruction ❑ Well Diameter Sealing Material d Depth r Depth Piller Material 5 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if + public sewer is ' available within 200 fest.) n Installation will serve: Residence, _ Commercial— Other Number of living units: Number of bedrooms (1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg z Capacity No. Compartments ' PKG. TREATMENT PLT.❑ - Method of Disposal Distance to nearest: Weil Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property-Line .. a i SEEPAGE PITS 11 Depth Size -Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ti I hereby certify that I have prepared this application and that the work will be done in accordance with Son 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 10 workman's Cornpensa- tion laws of California" The applicant ust II for at r ired inspections. Complete drawing on reverse side. Signed 4rnc.z—�� s Title:'° Data: FOR DEPARTMENT SE ONLY _ Application Accepted by Dare — Area Pit or Grout Inspection by Final inspection by Data Additional Comments: q ` Applicant - Return a I copse to: San Joaquin County P b is Health Services Environmental Health Permit/Services k T 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 t ,,_ 20 , 1 INFO � 3 I FEE AMOUNT DUEAAMOUNT REMITTED CASH CEIVED BY +iOATE PERMIT NO. EN 17•24 INEV. ih sf C/!� Ll../ 69' ��I,..� -9Z 9z- a�