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r APPLICATION 1111111116 0 1P ." SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION -Tlv(j, 0 7 r Z 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 Manthey Road at Downing Avenue City Stockton Lot Size/Acreage owners NameCity of Stockton Address 425 N. E1 Dorado St Phone 4230 Kiernan Ave., #105 ContractorThe Twining Labs AddressModesto, CA 95356 License No. C575061 5� -8341 wim TYPE OF WELL/PUMP: NEW WELL2` WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well C) DISTANCE TO NEAREST: SEPTIC TANK 3 0 0 ' SEWER LINES 500 ' DISPOSAL FLD.3 0 0 ' PROP. LINE1 0-200 ' FOUNDATION 500 ` AGRICULTURE WELL .2-50-0 'OTHER WELL 500 PITS/SUMPSI 900' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom O Manteca Dia. of Well Excavation 7 —incDia. of Well Casing 1 —inch * Domestic/ Private 1 Gravel Pack O Tracy Type of Casing Specifications 1 11 PVC_ I'I Public 1-1 Other Delta Depth of Grout Seal ar ' Type of Grout sand. ci;im. I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Twining Repair Work Done U Type of Pump N A H.P. N/A State Work Done Gas probe install at on Welt Destruction O Well Diameter 1 " Sealing Material i Depth Ren t an i t A Depth 2 (d 13' Filler Material i Depth ,Sand cement G111rry PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg PKG. TREATMENT PLT. O I I (No septic system permitted if public sewer is available within 200 feet.) Water tattle depth - Capacity No. Compartments Distance to nearest: Well Foundation LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Method of Disposal Property Line Total Well Foundation Property Line SEEPAGE PITS I I Depth Sue Number c E SUMPS LI Distance to nearest: Well Foundation Property Line ECE6 1f E DISPOSAL PONDS O M-tr"zR-1-5—loos I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countpfd° d rules and regulations of the San Joaquin comity �AN JUmr I.UUIV1��(� Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which�is�i�!?lt�rI��tY`'to�ci employ any person in such manner as to become subject to workman's compensation laws of California." Contractorstat�tir�>rta`ure 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 ca for all requtr inspections. Complete drawing on rove a side. Signed X �x��. .✓� Title: _�!�'�' Date: �^ FOR DEPARTMENT USE ONLY ` Application Accepted by �'—� �/ �� Date ��r/ Area Pit or Grout Inspection by Additional Comments: Date Final Inspection by Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 EM 13.24IREV. rias' EK 1 4.28 Date FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. 3