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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC IIEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRF_s,9 I YEAR FROM DA'Z'E ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the kDnfe1:�.Jnf iThis application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 andthe San Joaquin County Public Health Services. Job Address 1766 Monte Diablo Avenue City Stockton Lac Sia sx 83 ' ( 209 ) Chapin Brothers Owner's Name r Inc Address 1203 N. Carlton Avenue Phone 464-4349 Contractor Woodward Drilling AddressP •O• Box 336 ,Rio Vistt`f�ense No. 581639 Phone 707-374-4300 TYPE OF WELL/PUMP: NEW WELL N WELL REPLACEMENT n DESTRUCTION O Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES 50 ' DISPOSAL FLO. N/A PROP. LINE 1 7 ' FOUNDATION _-LOLL— AGRICULTURE WELL N/A OTHER WELL N/A PITS/SUMPS N�A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f.7 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation 10—1 2" Dia. of Well Casing 411 U Domestic/Private Rl Gravel Pack [.A Tracy Type of Casing PUC SCh. 40 Specifications 5- 1 0 ' Type of Groutbentonite/ em( L7 Publi� 11 Other ❑ Datta Depth of Grout Seal T 14onitoring25 ' Woodward Drilling ❑ IrnUatron _ Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction O Wolf Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION Cl fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. b Length of lines _ Total length/size FILTER BED 1.1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San 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 to workman's compensa- tion laws of California." The applicant must call for all require s i ns. Complete drawing on reverse side. ,4�_ Senior Geologist 11 -09-90 Signed ) Title`: Date: - 'FO'R D P TMENT USE ONLY / ri L Application Accepted by c� {// Date /%/Z T--- Area 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 DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKT'ON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CKs INFO CASH RECEIVED By DATE PERMIT NO. _ EH 1374 Inty -A