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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ��(/ <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 U�7 L Z <br /> P 0 BOX 2009, STOCKTON, CA 35201 <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 vork herein described. This <br /> AMPlicJoaquin Con is Pude in compliance with San Joaquin County Ordinance Ho. 5k9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Manthey Road at Downing Avenue <br /> City Stockton Lot size/Acreage 58 <br /> owners NameCity of Stockton Address 425 N. E1 Dorado St <br /> 4230 Riernan Ave. , #/1 05 Phone (209 ) 9a9-8 �� <br /> Contractor The Twining Labs AddressModesto, CA 95356 License No. C575061 5.5�hone( 209 ) 545-1 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT77 DESTRUCTION ❑ Out of Service i:e12 O <br /> PUMP INSTALLATION rC SYSTEM REPAIR O OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK 3 0 0 SEWER LINES 5 O O ` DISPOSAL FLD.3 0 O r PROP. LINE1 O—2 0 O r <br /> FOUNDATION 5 0 0 ' AGRICULTURE WELL -2-5-0 0 `OTHER WELL,5 0 0 ` PITS/SUMPSI 9 0 0 ` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 5—ow Bottom O Manteca Dia. 0/Well Excavation —1nC 1 —inch <br /> * Domestic/Private R Gravel Pack O Tracy Type of CasDia. of WOO Casing <br /> i'1 Casing Specificationsa " �ij7.G <br /> Public n Other 0 Delta Depth of Grout Seal ' <br /> I I Irrigation 6 Type of Grou <br /> _ <br /> Approx. Depth I I Eastern Surface Seal Installed by Twining <br /> Repair Work Done O Type of Pump _ALA_ H.P.__NSA State Work Done Gas probe installat' <br /> Well Destruction O Well Diameter 1 " Sealing Material & Depth ?inn t nn 1 t a <br /> Depth —2 la 11 Piller Material & <br /> DeFth fianc3 nAmant• c 1 31?-r7TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it <br /> available within 200 feet.) public sewer is <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: <br /> SEPTIC TANK O Type/Mfg Water table depth <br /> Capacity. <br /> PKG. TREATMENT PLT.O No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE O No. & Length of lines <br /> FILTER BEDTotal length/size <br /> O Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS I I Depth size <br /> SUMPSNumber <br /> LI Distance to nearest: Well® Foundation <br /> PfOpeLine PONDS -----RECEIVED <br /> I hereby cartify that I have prepared this application and that the work will be done in accordance with San Joaquin count i <br /> rules and regulations of the San Joaquin County �prd TNAuf fsa>;q,�„yov�d <br /> Horne owner or licensed span's signature certifies the following: AN JU N I.UU' �c <br /> employ an rk ��I certify that in the performance the work for r'sK4V i{ feat i�C'�Sae� � •hoe <br /> Y person in such manner as to become subject to workman's compensation laws of California.-mContractors , <br /> certifies the following:"1 certify that in the performance of the work for which this �G to wor/focalt� Tslgriait ry 10l <br /> tion laws of California.,' permit is issued. I shall employ persons subject to workman's compensa- <br /> The applicant must 5011 for all faQui�0 inspections. Complete drawing on revs side. <br /> Signed x`---rcj <br /> Title:®/'✓TNf'9L Date: <br /> � FOR DEPARTMENT USE ONLY / ` <br /> Application Accepted by Date 3�i5`f.> <br /> ---�! Area <br /> Pit or Grout Inspection by Date <br /> 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 A San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO y/(� /y� CASH RECEIVED BY DATE PERMrT'NO. <br /> EK tY?a TREY.�,a <br /> .41 <br /> !fl� 0 D 8�• <br /> Eot Ica <br /> � . �s � 5530 <br />