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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY- PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE, , PHONE (209)46$-3420 � � L P O BOX 2009, STOCKTON, CA 95201 ' IRRS 1 VVAD R M ` D �✓* (Complete in Triplicate) appli ation is hereby mad Han 4r," County for a permit to construct and/or install the cork herein depplication is made in compliance San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San 6 Joaquin County public Health Services. Job Address 50' S 0 MIDDLE RIVER BRIDGE' City Lot Size/Acreage Owner's Name SPRINT Address 3807 CORONADO AVE STOCKT AMERICAN CONST & SUPPLY ; INC, ON CA phone 209 941-0917 Contractor - 1038 REDWOOD HWY ##2 MILL VALLEY Address CA 949 License No. 310599 (415) 381-0 38 TYPE OF WELL/PUMP: _ NEW WELL ---Phone rt WELL REPLACEMENT ❑ DESTRUCTfON ❑ Out of Service Hell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE 70 NEAREST: SEPTIC TANK OTHER ❑ Monitoring Well n — � SEWER LINES N/A DISPOSAL FLD. N APROP. LINE" N/A FOUNDATION N A AGRICULTURE WELL NIA/ .G»z' INTENDED USE OTHER WELL PITS/SUMPS N/A TYPE OF WELL-- PROS LEM AREA--- CONSTRUCTION SPECIFICATIONS n Industrial - ❑ Open Bottom ❑ Manteca Dia. 01 Well Excavation Y El Domestic/Private Cl Gravel Pack Dia. of Well Casing 2-2 ❑ Tracy Type of Casing-_ PVC SCH 40 Il PublicSpecifications (Qa1 Other 1 (� Delta Depth of Grout Sea! 50 r 1 1 Irrivation Type of Grout if CRET 1-QeApprox.,Depth I I Eastern Surface Seal Installed by TREMIE METHOD Repair Work Done - U Type of Pump I_ N{)NF. H.P. State Work-Done Well Destruction O Well Diameter t 10'w`' Sealing Material & Depth CATHODIC PROTC. Depth 1009 Filler Material i Depth TYPE OF SEPTIC WORK:. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is 1 Installation will s/rve: Resid available within 2 encs, �Commercial�, O;her�` 00 }eat.l Number of livingunits; i Number of bedrooms Character of soil to a depth of 3 feet: r i SEPTIC TANK 0 Type/Mfg = Water table depth PKG. TREATMENT PLT. ❑ Capacity-. No. Compartments Distance to nearest: WellFoundation Method ' s --��. Property Line q LEACHING LINE N P. ❑ No. & Length of lines A FILTER BED tal length/size ClC l Distance to nearest: Well Foundation—. property I9A 1N COUN)TY SEEPAGE PITS I I Depth PUBLIC HEALTH SERVICES SUMPS 5i:e Number ENVIRONINE L7 Distance to nearest: Well DISPOSAL PONDS ❑ ! Foundation Property Line hereby certify that 1-have prepared this application and that the work will be done in accordanceinri;, rules and regulations of the San Joaquin County ti San Joaquin county ordinances, state laws, and Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to tion laws of ifornia." p y persons subject to workman's compensa-- The applicaust l! fa a!I required inspections. Complete drawing on reverse side. Signed STEVE cKIM PROJECT MANAGER Title; Date; 6/17/93 D RTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by p Date Final Inspection by Additional Comments: Date ApplieaLat - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1501 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE- AMOUNT DUE INF AMAMOUNT REMITTED CK V CEIVED Y D TE PERMIT'.NO. • EH 1 - [REV.ainsi X 9 EH 11rAje -4 V [ 7 L