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APPL I C.,A T ON • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 AUG 16 1992 PERMIT EXPIRES 1 YEAR FROM DATE I01 OT i (Complete in Triplicate) ENMRO�N�rtMENFTALHEAiTH i x P kAet@'fh"H44MP This Application Is hereby msde,to SaniJoaquin County fore permit to construct and/or install the Work I application is made in compliancelvith San Joaquin County Ordinance No. 51+9 and 1862 and the"Rules and Regulations of San Joaquin County Public Health Services. r 57 13170 West Grant Line Road ciryTr� Lot Size/Acreage Job Address - - (408) 246-5001 "Richard Oliver Address 3600 Aruneridge, Suite 340 Phone Owner Name Santa Clara, CA 95051 Twining Laboratories r Address 2527 Fresno Street License No. C57 5_ 159 Phone 209 702 268- 1 P. Cont - ��.��— WELL 17ractor Y TYPE OF WELLIPUMP: NEW WELL d L REPLACEMENT DESTRUCTION Cl Out of Service Well ❑ 9T)l , Monitoring Well [I -PUMP INSTALLATION O- SYSTEM REPAIR C77 '�„�R'r'��nn�� SEWER LINES DISPOSAL FLD. 1 ADP. LINE V DISTANCE TO NEAREST: SEPTIC TANK - PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T+� C1 Dia. of Well Casing Industrial ❑ Open Bottom ❑ Manteca`" Dia. of Well Excavation Type of Casing_ Specifications .� [I Domestic/Private ❑ Gravel Pack ❑ Tracy r Type of Grout i'1 Public Cl Other ,` n Delta Depth of Grout Seal I } Irrigation Approx. Depth t I Eastern Surface Soul Installed by �1a of Pum H.P. State Work Done �J Repair Work Done 0 Type p Sealing-Material & Depth Well Destruction ❑ Well Diameter Filler Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1-I DESTRUCTION I I available blelw thin 200 feetc system .) if public sower is Installation will serve: Residence— Commercial Other — F Number of living units: Number of bedrooms Water table depth Character of toil to a depth of 3 feet: - No. Compartments i3 SEPTIC TANK Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT.❑ Distance.to nearest: Well Foundation Property Line { Total length/size ' LEACHING LINE ❑ No. & Length of tines FILTER BED -- ❑ Distance to nearest: "Well Foundation Property Line # SEEPAGE PITS IC Depth i Size Number SUMPS, - _ LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I 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: "t 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 taws of California.' The applicant must call for all require tion Complete drawing on reverse side. Signed X Title; �a ��• C DSte: { FOR DEPARTMENT USE ONLY Application Accepted by ` Date Area Date Final Inspection by M Date Pit or Grout Inspection by- y - - Additional Comments: e:-'r- Return all copies to: San Joaquin County Public Health Services (5 Environmental Health Permit/Services r - 445 N San Joaquin,•P 0 Box 2 , tkn, CA 95201 f FEE K ED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED . EM l32f IREV.ei n 5) 178-oa /y8 -opo �87� �