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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4010 E. Main St, city Stockton Lot Size/Acreage 1 /2 acre Owners 42) City of Stockton Address 425 N. E1 Dorado St. Phone( 209 949-8341 4230 Kiernan Ave. , #105 Contractor The Twining Labs Addre&odesto, CA 95356 License No.C575061 59 Phone( 209 )545-1 50 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Nsoigon orYllgIwell C7 gs DISTANCE TO NEAREST: SEPTIC TANK >2 0 0 SEWER LINES 50 DISPOSAL FLD?2 0 0 ' PROP. LINE 2 FOUNDATION 2-5-L- AGRICULTURE WELL L2_0V OTHER WELL_L2_0V PITS/SUMPS X 2 0 0 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N/A Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ N A Specifications. " borings I'I Public IN Other XXDeita Depth of Grout Seal N/A Type of Grout neat cemeri I I Irrigation 40.Arpprox. Depth I I Eastern Surface Seal Installed byTwining Repair Work Done L3 Type of Pump N A H.p, N/A ____ State Work DoneSOil borings Well Destruction O Well Diameter N/A Sealing Material & Depth N f A Depth 4 @ 40 ' Filler Material & Depth Bentonite neat cement TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_. Other Number o ' s- Number of bedrooms Character of soil to a dopth of 3 feet: a depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ------Property Line LEACHING LINE ❑ No. b Lengt rues Total length/size FILTER BED ❑ Dist to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISP L PONDS O 1 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: "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 r d inspections. Complete drawing on r�eJJ�erso sidle. /� y Signed X� !o" s� Title: _!,�eJ INel Z CT4391& it Date: FOR DEPARTMENT USE ONLY Application Accepted by _ �1 Date � r Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services C� Environmental Health Permit/Services f��+ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE .••/// INFO AMOU NT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EN 13-21 IREV,r i x si ( r,,/EH tz-ze `�V