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APPLICATION FOR PERMIT " . 777.,1 SAN JOAQUIN COUNTY'OPUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 Q T P O BOX 2009, STOCKTON, CA 95201 4 1990F ENVIRONIMENTAL'HEALTH Mi P sE dIT EXPIRES 1. YEAR..,FROM DATE 15SUM, PERMIT/SLERVICES (Complete in Triplicate) Application is hereby made to San Joaquin Count for 4 y a permit to construct and/or install the Work herein described. This application is made in compliance'vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services.. , Job Address 110 W. Turner Road ti City Lodi Lot Size/Acreage �N/A - Ili Owner's Name AT&T Communicat, ,.. Phone(209)367-9110 ions Address 110 W. Turner Road, Lodi � Bey] Drill°in 3429 Longview Drive 306291- Contractor g Address-NOrth Hi ghl and,5: CA License No. L-6] SC-61Phone 1916 485-07 2 TYPE Of WELL/PUMP: G NEW WELL .� ___ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 k MW-1, MW-2 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p(2) Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK 800 SEWER LINES ' 350 DISPOSAL FLD. NIA PROP. LINE FOUNDATION. 20 _,,. AGRICULTURE-WELL -40— OTHER WELL 300 PITS/SUMPS UQ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca pia. of Well Excavation 12 i nrh Dia. of Well Casing Cl Domestic/Private ® Gravel Pack 0 Tracy - Type of Casing SCh. .40 PVC Specifications 0-02 inch S l t iX fs,bFieMonl tori ng 1-1 Other 171 Delta N/A Depth of Grout Seal ahnitt 30 ft_ Type of Grout.b_en 0ni te- 1 I Irrigation" 45-Approx. Depth I I Eastern Surface Seal installed by tremi e cpment Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I Z INo septic system permitted it public sewer is = Ya• t g! available within 200 feet.) § Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK © Type/Mfg Capacity No. Compartments 9 PKG. TREATMENT PLT. Ll Method of Disposal i Distance to nearest: Well Foundation Property Line r: LEACHING LINE L-1 No. & Length of lines Total length/size FILTER BED 11 Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size — Number I SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS - ❑-_ - - __ _. 7- I I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County 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 employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X. 241� I Title: ESE Staff Geologist Date: 10-2-90 t Emi l i 0 Onzal eZ Jr. , CEG FOR DEPARTMENT USE ONLY Application Accepted by Date o Area yl�l Pit or Grout Inspection by _1�stA�.f �� _ Date�, Final Inspection by Date �1 Additional Comments: . Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEI INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 1 r EN 13-21(REV.I/n 5) t EH 14•2a _. _, 1 {