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1411 APPLICATION SAN JOAQUIN COUNTY PUBLIC HL LTH ENVIRONMENTAL HEALTH DIVIS 445 N SAN JOAQUIN, PHONE (209)9 P O BOX 2009, STOCKTON, CA c (Complete in Triplicate) 1_ -'H ,I-- rC�7 0 �7 VTOPS _IA'9n 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. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Ly�� j t1U ��7,�" /� /� }�i> i ff�.' A,'/C_� ��i;�� 15 miles south of Arch Road ✓ i..ti A 1-4-..,,-.,-- A-*-;- fMA k M---4-1- DA CitvStockton Lot Size/AcreageAiJprOX. 140 acres Owner's Name City of Stockton Address _ 425 El_Dorado Street Phone ( 209) 949-8341 The Twining 4230 Kiernan Ave., Suite 105 (209) Contractor Laboratories,- Inc. Address Modesto, CA 95356 License No. C57506159 Phone 545-1050 TYPE OF WELL/PUMP: fiTa.1 / YJ� NEW WELL XK WELL REPLACEMENT 0 DESTRUCTIONXN Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well XX DISTANCE TO NEAREST: SEPTIC TANK 7001 SEWER LINES 1200° DISPOSAL FLO. 700' PROP. LINE _5Q-_100' FOUNDATION 1 200 ° AGRICULTURE WELL 200' OTHER WELL -20DL- PITS/ SUMPS2Qol,-500' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fklndustrial V) EL it)_ 0 Open Bottom ❑ Manteca Dia. of Well Excavation8-inch Dia. of Well Casing 2 -inch f l Domestic/ Private CUravel Pack 17 Tracy Type of Casing Schedule 20 pyC -inch pp I'll Public I 1 Other Delta Depth of Grout Seal $21 _ Type of Grout 43 S I I Irrigation _._ Approx. Depth I I Eastern Surface Seal Installed by Twining l=[/IA Repair Work Done 0 Type of Pump Bladder H. P. 5 State Work Done Replacr!.ng monitoring we Well Destruction O Well Diameter 2 -inch Sealing Material & Depth ni tp Cpl 1 Pts from 82' t0 851 Depth Filler Material & Depth r,pjnpnt- gmit Ix'tJlll 2' to 82' 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 of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS O 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: "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 required inspections. Complete drawing on revArse side FOR DEPARTMENT USE ONLY Application Accepted by,� �� t _ Date -� F� r Area r r 4f / Pit or/Grotyt Inspection by �0 t ate J /Final Inspection by / i Z Date Additional Comments. 1� ST;;' '-' 'r � 6 r �(T r r lC w <t. `/" c, � �j/yu (it C1 � L /1 Gtr A'F Ayplic.ant - Re • EH 13.24 [REV, I/ AS EH 14.28 flat �y, iC?M o'-� ^�t crf /. vvt'. ebb' tl is San Joaqui Country%bIi Health Servides" Environmental Health Permit/Services 9 �1 - j.�oiNgg �,,VU 445 N San Joaquin, P O Box 2009, Stk., CA g 0 ld k_ 66111 a�a"J FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT' NO. w/VP. l p