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APPLICATION FOR fALO _ SAN JOAQUIN COUNTY PUBLIC ENVIRONMENTAL HEALTH445 N SAN JOAQUIN, PHONEP 0 BOX 2009, STOCKTON/9�01 PERMIT EXPIRES 1 YEAR FROM D V SU (Complete in Triplicat Application is hereby made to San Joaquin County for a Permit to construct and/or install the work herein escribed. This application is rade in conplie-nce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1751 Monte Diablo Ave. city Stockton Lot Size/Acreage -1 acre Owner's Name Russel Chabin Address 1201 N. Carlton Phone( 209 ) 464-4341 Contractor Quo-EnvironmentalAddressP 0. 3595, Yuba City License No. 676923 Pon 71_244 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Konitoring Well DISTANCE TO NEAREST: SEPTIC TANK _. _ SEWER LINES 40 DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS _ INTENDED USE D Industrial P Dome tic./Private I'l Public I i Imijalion Reoair Work Done U Well Destruction C TYPE OF SEPTIC WORK TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Open Bottom [I Manteca Dia. of Well Excavation 8lnche5 Dia. of Well Casing 2 inch X] Gravel Pack ❑ Tracy Type of Casing_ FVC _ _ Specificarion40- 020 �r'rpF (] Olhr:r n Deita Depth of Grout Seal 12 f t . Type of GrouKe.�4_ t Ment Appro::. Depth I i Eastern Surfacc Seal Installed by Drillers T yue of Pump Well Diameter _ Depth NEW IinSTALLATION I I H. P. _ State Work Done _ _ Sealing Feterial L DepthNpat C`NmPni J -n cr -fit Filler Material it Dept), #3 Monterey Sand to 14 f t. REP.1!R/ADDITION i I DESTRUCTION I I (No septic system permitted if pub!w sewer is available within 200 feet.) !nstsh.-,ion will r9rve: Rtraidence _. Commercial . Other Nw',ber of living units: Number of bedrooms qq Char.wter .;ifsell to a dept:) of 3 feet: r" Vy4tef iabl. depth _ :, r. SEPTIC TANK ❑ Type/Mfg Capacity— . II Coanpar-rnents i°KG. TREATMENT PLT. !A DIE C 2 4-M of Disposal Distance to nearest: Well Fourrdati i SAN_ Up�rily19,ne„I_ P06LIC HFA1 T” cr-n LEACHING LINE D No. & Length :,f lines L_1NVlrtUIyWTe%hi6te1LLb F!LTEP. 9E1 ^:e;,.^.cc ru. rcct. V c;`! -- '', rtc..; ; __..-----. rroperty Line SEEFACA PITS I i Depth _ .Size Number SUMPS LI Distinc& to ncaarest: Well _ Foundation ___ Property Linc, I G DiS PCiS•AL PONDS O I h9t,3by certify thvt 1 hiI prepared his application and that the ,work wiii be done in accordance with San Joaquin county ordinances, etsta II and rules and rKwlattons 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 paraon in such manner as to become subfect to workmen'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 Cs!ifornia." The applic t must call for ? r r inspetctions. Complete drawing on reverse side. Signed_ (�f_Sri_. V (__.__ _.- -- -----_ -- Title: UACX!//{V Date: FOR DEPARTMENT USE ONLY Application Aceopte+d by 4 _ Date l J Area �e 6. Fit or Grout Inspection by Date Final Inspection by Date n Additional Comnx ntt: - -�1/f �^^`-St�l�r �i/t Applicant - Return all copt.es tc: San Joaquin County Public Health Services FF.E^I AMOLINT DUt _ INFO + E-: t?:4 SRN, +/M5), �% �f� Environmental Health Permit/Services ♦\ 445 N San Joaquin, C'� Box 2,109, Stkr., CA -5201. c i 60�0\ I A410L'+,1T REMITTED � C•kSH •�/ RECEIVED BY �/�t�TC/J DATF PERMIT NO. 7 �J /�y//� �jY7�(7 L— -'- j (!I � J