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r y - APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE r I ENVIRONMENTAL HEALTH DIVISION E C 1601 E. HAZELTON AVE. , PHONE (209)468-3420 0 C T 4 1TOO ` P O BOR 2008, STOCKTON; CA 95201 ENVIRONMENTAL HEAI_T FI o' PERMIT EXPIRES 1_ YEAR FROM- DATE 15SUED �, �� t�flE�Ls (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 compliance withSanJoaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pblit Health Services. ., i r "' Job Address -5&' W_ Turner Rodd � '� City "Lodi Lot size/Acreage N/A .11 Owner's Name AT&T C n Address . Phone - 91 in 3429 Longview Drive 306291- contractor_Beyl i k Drilling Address North Hi ghl ands, _CA License No. C-57&SC-6khone 916 485-079 _ TYPE OF WELL/PUMP: __ wl NEW WELL,4= WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll t MW-3 /pPUMP INSTALLATION D SYSTEM REPAIR C1pOTHER C]/11) Monitoring Well � 1 DISTANCE TO NEAREST: SEPTIC TANK 1,100 SEWER LINES 600 DISPOSAL FLD. _ PROP. LINE 50 FEET FOUNDATION. 350 AGRICULTURE WELL 250 OTHER WELL_ PITS/SUMPS 500 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R industrial ❑ Open Bottom D Manteca Dia. of Well Excavation 12 i nch Dia. of Well Casinginch- . _4[D Domestic/Private ® Gravel Pack N/A D Tracy Type of Casing Sch. 40 PVC Specifications 0. 2-1n slot Ix S�rblie Moni tori ngri other n Delta Depth of Grout Seal dboLd K.ft— Type of Grout bentOni te- ' I I Irrigation 4.5-:.Approx, Depth I I Eastern Surface Seal Installed by tremae cement Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material & Depth i Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial_ Other - i 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 i PKG. TREATMENT PLT. ❑ d - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FiLTER BED C] Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well 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'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. 9--LTY5 Title: ESE Staff Geologist Date: 10-2-90 Emilio Gonzalez, Jr. , CEG FOR DEPARTMENT USE ONLY - �6/1/�Qb Area Application Accepted by Date - r Pit or Grout Inspection byDate // G p Final Inspection by Dated//� Additional Comments: 1q' a-W—e"e;act7 if, �rf 1.1 a rCGf /Irk'%d 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 t FEE AMOUNT DUE AMOUNT REMITTEDeCk RECEIVED BY DATE PER MIT'NO. INFO • EH 19-241REY.1/fl51 i' �S O_T /&_-m- qc '. Eli 44-26 }