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APPLICATION � On JOAQUIN COUNTY PUBLIC HEAM SERVICES ENVIRONMENTAL HEALTH DIVISION ol-7 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 cOmPliaace with San Joaquin County Ordinance Ho. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Manthey Road at Downin2 Avenue Citi. Stockton Lot Size/Acreage 58 owner's NemeCity Of Stockton Address 425 N. E1 Dorado St Phone (209 ) 949- 341 4230 Kiernan Ave. , #105 ConlractorThe Twining Labs AddressModesto, CA 95356 License No. C575061 5$hon4 209 545-1 c TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service hell O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O 14onitoring Well O DISTANCE TO NEAREST: SEPTIC TANK 3 0 0 ' SEWER LINES 5 0 0 ' DISPOSAL FLD.3 0 0 r PROP. LINE1 0-2 0 0 ' FOUNDATION 5 0 0 ' AGRICULTURE WELL -25 00 'OTHER WELLS O O r PITS/SUMPSI 9 0 0 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom O Manteca Dia. of Well Excavation /-3-nc Dia. of Well Casing 1 -inch n Domestic/Private g Gravel Pack O Tracy Type of Casing Specifications 411 Public n Other !R Delta Depth of Grout Seal 5 ' Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by TwininCJ Repair Work Done U Type of Pump _F2A m.p. __.N/A State Work Done Gas 2robe installatO Well Destruction O Well Diameter 1 er Sealing 0-terial & Depth Bentonite Depth -2 @ 1 3 ' Filler Material & Depth Sana cement- a 1 tirr3 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 fiving 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 M No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Lino SEEPAGE PITS I I Depth Size Number PAY ENT SUMPS Ll Distance to nearest: Well Foundation Property Line-----RECEIVED DISPOSAL PONDS O O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countrd d rules and regulations of the San Joaquin County �N Home owner or licensed spent's signature certifies the following: "I certify that in the performance of the work for which ' k"{_kQ;khslW I,"'� employ any person in such manner as to become subject to workman's compensation laws of California."Contractors ell , certifies the following: "I certify that in the performance of the work for which this permit is issued.1 shall employ o workman' companbn?a`�I`J tion laws of California.- The persons to workman's compensa- tion The applicant must ca I for all req�ui�inspections. Complete drawing on rove side. Signed X �. � Title: 1 --,::^�t-.tc•--- Data: FOR DEPARTMENT USE ONLY Application Accepted by v Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: Sam Joaquin County Public Health Services Environmental Health Permit/Services 445 h Sam Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNTREMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. EM 11•N tREV.I,aS �rvb 8 90D EN ta.'a