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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEAL? ENVIRONMENTAL HEALTH DIV] 445 N SAN JOAQUIN, PHONE (209 P O BOX 2009, STOCKTON, CA (Complete in Triplicat -!'AffhICES r&3 2 0 Application 1s hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of Joaquin County Public Health Services. q&(,-1,;, r '/7i ri ' —r 1 1.5 miles south of Arch Road A . 14C ti A.r.4. . hpf wppn Anci-i n Pei R hl"ar-aci-1 m Ari City Stockton Lot Size/Acreage pprox_ This San 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 Laboratoriesr Inc. Address _Modesto, CA 95356 License NoC57506159 Phone 545-1050 TYPE OF WELL/PUMP: NEW WELL :& WELL REPLACEMENT n DESTRUCTION Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 700' SEWER LINES 1200' DISPOSAL FLO. 700' PROP. LINE5.Q—1 00' FOUNDATION 1200' AGRICULTURE WELL 200r OTHER WELL 200' PITS/ sumps 20=500' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Nust! ! O Open Bottom O Manteca Dia. of Well Excavation —8—i nc-h Dia. of Well Casing 2—inch f I Domestic/ Private Gravel Pack O Tracy Type of Casing---- lE'_ LU pVC S 1nC p1� g___ pecifications — 11 Public I 1 Other KDeha Depth of Grout Seal Type of Grout sand cement I I Ir(it)ation 9_0r_ Approx. Depth 'XI Eastern Surface Seal Installed by Twining /,'///J L>it l _Badder H.P. 5 _ State Work Don e lacin monitoring wet Repair Work Done L7 Type of Pump eR � g g Well Destruction O Well Diameter 2—inch Sealing Material & Depth Bentonite nellets frQU 82' to 85' Depth 125' _ Filler Material i Depth Sand cement grout from 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 i 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. O Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE L -I 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 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 required inspections. Complete drawing on rev ,r'seosidde. Signed X s. Title: --��f C9r�r�li�� Date: ' FOR DEPARTMENT USE ONLY Application Accepted by �Lz4ti_Dat2-�� Area !/ t ' iC. i Pito Grout lhepection by ' lti Date t % Final Inspection by !� t Date `� `�5` Additional Comments: f5,/Y; , � rL �/ !. r v /,2; t 7 /j/i %// y, J �/_ l �l 2 { i<'i %k4 / ie " w t' 7e Applicant - Return all copies to /• EH 1 24 (REV. v n Sr (H 14 28 San Joaquin County Public Health Services Lt3'tfo6 s&oolgtid-=TNU 9010 Environmental Health Permit/Services LJ �(P SR,6DA`tg1 - TNV 445 N San Joaquin, P O Box 2009, Stkn, CA 520 INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO iaeti --t� i�