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' APPLICATION FOR PERMIT SAN _0AQUIN COUNTY PUBLIC HEALTH S oRVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ' P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRAM DATE I$SUED (Complete in Triplicate) ' Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application in made in compltance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ' Job Address 110 W. Turner Road City LOBI Wt size/Acreage N/A _ Owner's Name AT&T Communicatlpns Address 110 W. Turner Road Lodi Phone( ' 3429 Longview Drive 3062.i1- contractor__ B2Xl i k _Drl 11 ing Address License No Phone 91 485—M 2 TYPE OF WELL/PUMP NEW WELL Ig WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ MW-1, MW-2 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O(2) Monitoring Well 0 DISTANCE TO NEAREST SEPTIC TANK _ 800_ SEWER LINES 350 _ DISPOSAL FLD NZA PROP LINE 2Q_ FOUNDATION --2(L— AGRICULTURE WELL JQQ-.,. OTHER WELL M00 PITS/SUMPS 3M INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industnal O Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing n Domestic/Private I@ Gravel Pack ❑ Tracy Type of Casing Sch. 40 PVC Specifications inch S t tX PnbbeMo n i to ri ng n other f-1 Delta N/A Depth of Grout Seal ahntlt 30 ft Type of Grouthentoni te-, ' I I Irrigatwn 4-51-Approx Depth I I Eastern Surface Seal Installed by tremi a Cement Repair Work Done ❑ Type of Pump HP State Work Done_ Well Destruction 0 Well Diameter Sealing Material i Depth ' Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet I • Installation will some Residence_ Commercial— Other INumber of living units Number of bedrooms Character of sod to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments t PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line ' LEACHING LINE ❑ No & Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number ' SUMPS Ll Distance to nearest Weil Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will 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 a compensation laws of California"Contractoes hiring or subcontracting signature certifies the following "I eeMfy 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 dravoing on reverse side Signed a i Title ESE Staff Geologist Date 10-2-90 ' Emilio Onzal ez, Jr. , CEG FOR DEPARTMENT USE ONLY Application Accepted by _ _ Date Area Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments oppliCant - 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO EH 1324(REV EH 4 26