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APPLICATION FOR jDfirF T SAN JOAQUIN COUNTY PUBLIC S ENVIRONMENTAL HEALTH �., 445 N SAN JOAQUIN, PHONE 20k8-3420 P O BOX 2009, STOCKTON PERMIT EXPIRES 1 YEAR FRO I (Complete in Tripllcate i Application is hereby made to San Joaquin County for a permit to construct and/Is erl n ascribed. This application is made in cocpliance vith San Joaquin County Ordinance No. 549 a and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1766 Monte Diablo Ave. city Stockton Lot Size/AcreageI -a(-rL-- Owner's Name Russel Chapin Address 1201 N. Carlton, Stockton PhonA 209) 464- Contractor Geo—Enyi ronmenta'Address P • 0. 3595 Yuba City License No. 676923 (ph TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER AVW Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 100 f t • DISPOSAL FLD. PROP. LINE TYPE OF SEPTIC WORK: NEW !NSTALL.ATICN I I REPAIR/ADDITION I I DESTRUCTION I I I".'o septic system pwmwerl if public sewer is available within 200 iset.! InstadHzion will serve: FOUNDATION AGRICULTURE WELL. OTHER WELL. PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS SEPTIC 'TANK 0 Industrial O Open Bottom D Manteca Dia. of Well Excavation 2 i n _ Dia. of Well CasingQ? _2_ 1 ri . — CI Domestic/ Private �1 Gravel Pack ❑ Tracy Type of Casing- PVC Specifications -0"U scree Distance to nearest V1.0 'l Public (-I Other n De,:a Depth of Grout Seal 12 f Type c! GroutNeat Cemetl I I Irrigation _Aplxox. Depth I I Eastern Surface Seal Installed by Drillers___ Foundation ._ SEEPAGE PITS Repair Work Done 0 Type of Pump H. P. _ State Work [sane SUMPS LI Well Destruction 0 Well Diamet%- rI io Sealing Material & Depth Neat Cement - .5 ft. 2 5_{,� filler Material i Depth #- Monterev Sand — 14 f t . Depth __. --- � TYPE OF SEPTIC WORK: NEW !NSTALL.ATICN I I REPAIR/ADDITION I I DESTRUCTION I I I".'o septic system pwmwerl if public sewer is available within 200 iset.! InstadHzion will serve: Residences __ Commercial _ Other _ Nur,.:)er of living units: Number of bedrooms Character of sod to a depth of 3 fest: SEPTIC 'TANK 0 Ty-,e/Mfg - Cspac,t/ !'KG. TREATMENT PLT. 0 Distance to nearest V1.0 Foundation _ LEA;;HING ONE CI No. b Length of !ines _ FILTER BED ❑ Distance to nnr.regt: Well Foundation ._ SEEPAGE PITS I I Dvpth Sir_ SUMPS LI Distance to nearest: Woll _ Foundation _ DISPOSAL PONDS ❑ 1Pvater table depth . _ ':c. Co,npartments _ Method of Diso;sal —_ Propc>, ry line Toal length/size- Number Property L;ne I hereby certify that I have prepared this application and that the work .will be done in accordance with San Joaquin county ordinances, stere 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 taws of California." Contractor's hiring or sub -contracting signature certifies the following: "I unity that in the performeoce of the work for which ,his permit is issued, I shal! employ persons subject to workman's compen"- tion lows of Californla." The apph nt ust call for all r uir llinspections. Complete drawing �on reverse side. Signed jj,4A tv C'1 - - - - Title: ClJ�%�_ Lam— - -- Date:y� --- FOR DEPARTMENT USE ONLY / QCstApplication Accepted by Data f v D �� _ Area � w O: �� 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 Permit/Services \ 445 N San Joaquin, O Box 2009, Stkn. Ca OIF E AMOUNT DUE ^AMOUNT REMITTED CK !� RECEIVED BY EH 044 Ince.(//][�1 :H' 14'20 __ __._ .._-.-�J.___ , ._.__. I PERMIT N0. zlv .5 1001$60 .