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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 9520 . (209) 468-3447 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct end/or install the work herein described. This application is made in ccoVIiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1 766 Monte Diablo Avenue City Stockton Lot Sise/Acreage 1 38 ' x 83 ' Chapin Brothers , Inc'Address Phone 1203 N. Carlton Avenue X464} Owner's Name 4349 Contractor Woodward Drilling Address P.O. Box 336 ,Rio Vistaense No. 581639 Phone 707-374-4300 TYPE OF WELL/PUMP: NEW WELL 79 WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 9 DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES 50 ' DISPOSAL FLO. NSA PROP. LINT _E! FOUN601614 40 AGRICULTURE WELL N A OTHER WELL N/A PITSJSUMPS N/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17-1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation {1_7 7" Dia. of Well Casing 411 U Domestic/Priysle RI Gravel Peck n Tracy Type of Casing PVC Sch. 40 Specifications M Ptibli� i'l Other O Delta Depth of Grout Seal 5—10 Type of Groutbentoniteemi U irrigafilonitoring251pprcix, Depth ❑ Eastern Surface Seal Instilled by Woodward Drilling Repair Work Dona U Type of Pump H,P. State Work Done _ Well Destruction © Well Diameter Sealing Material & Depth Depth biller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADOITION 0 DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will sArve: Residence_ Commercial— Other Numbil of living units: Number of bedrooms Character of toil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartrnenti PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No, ii Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property-Line SEEPAGE PITS 11 Depth Sire Number �fwV SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby dcitify that t hAV6 6408red this application and that the work will be done in accordance with San Joaquin county ardinanees, state laws, and I'U41 Jfld 4016116AI 61 fhi Sire JoipulA Cathay Home owner or licensed agent's signature certifies the foWwing: "I certify that In the perlormance of the work for which this permit is issued, I shall not ' employ any person in such manner as to become subject to wo6man's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: 1 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 require s ns• Complete drawing on reverse side, Signed Title: Senior Geologist Date: 1 1 -09-90 F DEPA T USE ONLY Application Accepted by Date L a �3 3 Pit or Grout Inspection by Date 444pl Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 FEEi INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.