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T' 4),-, :• "^,P <br /> .v <br /> N COUNTY PU$LI <br /> ��SAISRIVICES;il""' <br /> AN Q gF D 0 Q <br /> S RONMFNT� ALT <br /> ONE V & ` <br /> 5 N AN JOAQUIN, PHQ # <br /> BOX 2009, STOCKT „hM� <br /> P 0 1 YS R <br /> 4 T IR 1•c ) j01 <br /> (Complete in Trip eaoribed. Thi <br /> +� lations,of Ban g <br /> or <br /> Joaquin County for a permit to <br /> cc at t an 2 and the Rules end Regu <br /> to San ordinance No. <br /> `1►gplication id hereby tie. uin County , <br /> application in made 1n co4liance with San Joao 5 8 <br /> y JoaqulA County Public Health services. City Stockton Lot size/Acreage <br /> Road at DOW Ave <br /> MaTithe Phone(2 0 9)9 4 9-8 3 41 <br /> ,lob Address 425 N. E1Dorado <br /> of Stockton Address Aver Ste 105 545-1110' <br /> Cit 4230 Kiernan C57506159ponee , ' <br /> e � owner s Nome CA 9 5 3 5 6 License No.____---- <br /> The Twinin Inc Address Modesto. DESTRUCTION out of t3ervics Well <br /> K § n LabOratOrl S WELL REPLACEMENT ❑ Motkitoring ] � <br /> Contractor NEW WELL OTHER D <br /> SYSTEM REPAIR C1 ft PROP, LINE <br /> 1_. <br /> P TYPE OF WELL/PUMP PUMP INSTALLATION O i5wpISPOSAI PLD. --- 2000 ft, <br /> r�+ <br /> SEWER LINES1 - -- OTHER WELL ft-- PITS/SUMPS t...- <br /> » QISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WA <br /> FOUNDATION -- CONSTRUCTION SPECIHCATtONS Dia of Well Casiinng- <br /> TYPE OF WELL PROBLEM � <br /> INTENDED USE Q Manteca Dia. of Well Excavati Ae 20 gpecificafwn� W . <br /> p peen Bottom Type of Casing_�a �'�' Tyt�of Grout <br /> L"j Industrial Gravel Pack O Tracy 42 it 5% <br /> o0 'HCl p mastic/Private , pelta Depth of Grout Seal tnP1J <br /> O �QBr (a Other Surface soul ins talled by1 �.3a <br /> y F pirbltc APProx, Depth I I <br /> Eastern 5 State Work <br /> Done .. <br /> 4r .+ P1 jrrigaiion H.P. 21- <br /> TYpe of Pump Sealing Material i Depth <br /> A ? , `':Repair Work Done Ll Well Qi a 2- <br /> Wsn Destruction Q Filler Material Depth tic system per mIliad if pub lic sawar is <br /> N � •.. Depth <br /> available within 200 feet.) <br /> 0 »_„ CATION I t REP)kI DOITION I I DESTRUCTION t 1 <br /> (No sap <br /> "' ,•TYPE OF SEPTIC WORK: NEW V �r <br /> Commercial __ other <br /> ` •+R� 1 ih <br /> Instanotion will serve: Residence # <br /> u its; .r...-- .Number of bedrooms <br /> Numhot of living n depth of 3 feet: <br /> Ghsracter of son to a Capacity__---------- 4 <br /> LJType/Mfg f <br /> SEPTIC TANK Properrt�L• ® C <br /> q a EATMENT PLT,f-1 Well ------ Foundation ------ <br /> Distance to nearest: l)iNrr <br /> To � 4100 <br /> r�S <br /> S <br /> No, 4 Length of lines <br /> 1 <br /> CI. <br /> Foundation <br /> --------- HD <br /> - <br /> Lt+ rest: <br /> AD�11Nf3�t E Well <br /> FILTE S9a <br /> � Distance to nes <br /> a, ! Number y <br /> Silo _----- property Line ----- <br /> O 1 1 Depth Foundation_.__----- <br /> $EEPRNOW! <br /> F' �T � Olstance to nearest. Well --- <br /> ermit is issued, 1 sh®n not is application and that the work will be done in accordance with San Joaquin county ordinances, state , <br /> & f DISII"t? ra rod this PP <br /> RitY thA hayt P Pe, dormance of the work for which this p nature` <br /> .. uln county ,l certify that in the Pe <br /> M• ituNn►,. unit nt ,>lj9 q <br /> nature certlf 10s the following ' rmit is issued,1 shall smptoy persons subject to workman's cotrenss <br /> � to become subject to workmar►'a compensation laws of California." Contractor s hiring or sub-contrscun <br /> such,rlNnnet fta tha work Tor which this pe <br /> p�y�{�� "I ArtifY that In the partormsnce of , <br /> � on t verse side � <br /> tions Co pweto 01Rwlt►p .,, ,� ,Date: 3 <br /> Titie, p <br /> a' W' DEPARTMENT US <br /> ONLY„ <br /> FQR Area —� <br /> $ � ;t pets <br /> 77 <br /> ate <br /> » F nal Inspection bye y�D <br /> � 3a1' <br /> R Services �� NV 93A <br /> kSan..Joaquin,County <br /> Public <br /> " Real h6 <br /> 0 , <br /> a . 0 q .ts� opiee to,s Snvironmental,Healtb Peroxt2009v,ices <br /> Stkn;''oA <br /> ' 445 N San Joaquin ePE ! <br /> y K RECEIVED By ATE <br /> a , <br /> < AMOUNT REMITTED CAS <br /> F1rli Ah!Sat1NT <br /> ° IT VII <br />