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- APPLICATION <br />JOAQUIN COUNTY PUBLIC HEA SERVICES <br />ENVIRONMENTAL HEALTH DIVISION Ti)tj, 7q Z <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />P 0 BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br />application is made in compliance with San Joaquin County Ordinance No. 51+4 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />Job Address _Manthey Road at Downing Avenue City Stockton Lot Size/Acreage 58 <br />Owners NameCity of Stockton Address 425 N. E1 Dorado St. Phone 20 949-834 1 <br />4230 Kiernan Ave., #,E105 <br />ContractorThe Twining Labs AddressModesto, CA 95356 License No. C575061 5!�ho4 209).545-1 C 5 <br />TYPE OF WELL/PUMP: NEW WEL03% WELL REPLACEMENT ­n DESTRUCTION O Out of Service Well O <br />PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well O <br />DISTANCE TO NEAREST: SEPTIC TANK 3 0 0 SEWER LINES 500 ' DISPOSAL FLD.3 0 0 ' PROP. LINE1 O —2 0 0 ° <br />FOUNDATION 5 0 0° AGRICULTURE WELL -250-0 'OTHER WELL 5 0 0' PITS/SUMPSI 900 <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />n Industrial O Open Bottom O Manteca Dia. of Well Excavation —1riC Dia, of Well Casing 1—inch <br />* Domestic/ Private R) Gravel Pack O Tracy Type of Casing Specifications 4 <br />I') Public rl Other Delta Depth of Grout Seal e ° Type of Grou j <br />I I Irrigation , Approx. Depth I I Eastern Surface Seal Installed by Twining <br />Repair Work Done U Type of Pump N A H.P. N/A State Work Done Gas 2robe installat: <br />Well Destruction O Well Diameter 1 1° Sealing Material i Depth Ben tan 1 t= <br />Depth 2 A 1 3 ° Filler Material i Depth SaI)d cemenf s111rry� <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial _ Other <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth _ <br />SEPTIC TANK O Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT, O Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />FILTER BED O <br />No. & Length of lines Total length/size <br />Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS LI Distance to nearest: Well Foundation Property Line ------RECEIVED <br />DISPOSAL PONDS O , r- ,,,,,,. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count rdir� p g1at��—w�,apc <br />rules and regulations of the San Joaquin CountyPN JH�I I fV I.0 U I'd I 1 <br />Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which ilt'ik&slii�VAy;oi <br />employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor'si/#tniaeQara�Tsigrea�t�i <br />certifies the following: "I certify that in the performance of the work for which this permit is issued. 1 shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The applicant mus" �0 for all�requirgo inspections. Complete drawing on revegse side. <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by��J'3'_i-� C,;Z, 3��rj� a <br />v Date Area <br />Pit or Grout Inspection by Date Final Inspection by Date <br />Additional Comments: <br />Applicant - Return all copies to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 R San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br />EM 13.24 fREV. lin 51 <br />EM 16.20 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CASH <br />RECEIVED BY <br />DATE PERMIT'NO. <br />�� <br />POD <br />€'f -q <br />�S � 5 3 <br />