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APPLICATI0N FOR PE SAN JOAQUII? COUNTY PUBLIC HRTAAHi�14 ENVIRONMENTAL HEALTH DjVYS 445 N SAN JOAQUIN, PHONE ,( 46 - P O BOX 2009, STOCKTO9, A 95201 PERMIT EXPIRES 1 YEAR FI TE I SUID (Complete in Trift2;!_inta�sll Application is hereby made to San Joaquin County for a permit to consthe work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules 'ecilat:ons of San Joaquin County Public Health Services. Job Address 1812 Monte Diable Ave . Cit. Stockton Lot Size/Acreage 1-ACRE Owner's Name Russell Chapin Address 1201 N. Carlton, Stockton Phond 209 ) 464-434 ( 800) Contractor Geo-EnvironmentalAddress P.O. 3595 , Yuba CityicenseNo. 676923 Phone671-2424 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHERft iiouitcring Well XX DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 30 f t . DISPOSAL FLO. PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom O Manteca Dia. of Well Excavation 8_ Dia. of Well Casing Cl Domestic/Private NGravel Pack O Tracy Type of Casing_ PVC Specifications 0 .020 Screen "1 Public Cl Other i1 Delta Depth of Grout Sezi 12 f t . Tyo^ or Grout Neat Cement I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Drillers Repair Work DGAe 0 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Neat Cement 5 f t . Depth 'tiller Material i Depth #3 Monterey Sand - 14 ft . —_ TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/AOD!TION I : DESTRUCTION I I !No septic system petm::tru ,t ouni:; sewer available within 2W feet.) Installation will servo: ReNdencs _ Commercial _ Other Number of living units: Numt)er of bedrooms Cparacter of sot! to • dcbth cf 3 'eet: _ Water tao;e a•ptn —_—_—__—_—.— SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal __ __— 'r Distance to nearest: Well '-oundetion Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BEC Ci Distance to nearest: Well Foundation 'rope ty SEEPAGE PITS I Depth _ Size Number SUMPS LI D!stanca to nearest: Well Foundation Propenv Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Jeaqun count, ordinances. stats lows, and rubs 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 :s=urd. I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting si;nature certifies the following: "I certify that in the performance of the work for which this permit iz issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The appliggAuv call for all r inspections. Complete drawing on reverse side. jf 1�20_q Signed Title: - � ' �"" 'it ----- rats --- 1�0 FOR DEPARTMENT USE ONLY Application Accepted by Date IV30/93 i reb ^ A_�ro Pit or Grout Inspection by .D.ate_� - Final inspection by � Uats�C Additional Comrnents: +✓�.L/4 r� 1764 Applicant. - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N Sen Joaquin, P 0 Box 2009, Stkn, OA 9520; FEEi INFO AMOUNT DUE AMOUNT REMITTED (C<)H RECEIVED BY DATE PCRMP NO j • EM13.24(REV,r 1"14%; •./ "��