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' r 1 <br /> APPLICATION FOR PERIWIT <br /> SAN JOAQUIN COUNTY PUBLIC SEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 R. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RIPERNIT EXPIRES 1 YEAR FROM DATE -ISaUED <br /> I (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance',with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address S 9141)7 LA/. 150.3' A/ 0 elleQIAIM AWCity LODI Lot Size/Acreage <br /> Owner's Name PG&E Address POB99 930 Stockton. CA 95201L Phone 442-3 42 <br /> General Const Address 4056 E. HW _120 _ License No. Phone <br /> CvRlraclvf ,K- - <br /> TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out qr Service Well ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ nitoring Well 0 <br /> PUMP INSTALLATION O 141 <br /> (STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI E <br /> r FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial Open Bottom ❑ Manteca Dia. of Well Excavation 1 011Dia. of Well Casing <br /> Specifications-- <br /> Cl Domestic/Private ❑ Gravel Pack Type of Casin❑ Tracy g 8719 ;ack mix <br /> I'l Public Fl Other n Delta Depth of Grout Seal Type of Grout <br /> y _ _AppraK.'Depth I I Eastern Surface Seat Installed by <br /> ARV8n Well H.P. at Wor one, <br /> Repair Work Done D Type of PumpO�cre'te <br /> Material i Depth <br /> Wel! Destruction ❑ Well Diameter Sealing U @ Breeze <br /> Depth Filler Material & Depth <br /> F SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I iNo septic system permitted if public sews <br /> available within 200 feet.) <br /> Installation will se • Residence_ Commercial Other <br /> Number of living units: umber of bedrooms ) <br /> Character of soil to a depth of 3 feet: er table depth <br /> 1 <br /> SEPTIC LANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ # Method of Disposal ) <br /> Distance to nearest: Well ation Property Line # <br /> LEACHING LINE ❑ No. & Length of lines engthlsixe <br /> 1`1111 fid will �, ,�,,, fiallo ,�,�1� Pfd 101 <br /> SEEPAGE PITSDepth i I Size Number <br /> 5UMPS LI Distance to nearest: Well Foundation Property Lina <br /> AL PONDS ❑ 1 <br /> 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 <br /> rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to' become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion Iowa of California." <br /> The applicant ust call for all required ' 7speetions. Complete drawing on reverse side. <br /> i Signed Engineer ineer - Estimator <br /> l <br /> Title: Date. 4-20-90 <br /> F DEPARTMENT USE ONLY l 3 <br /> f <br /> Date, �� � — Area <br /> Rate <br /> Ction by ' <br /> Finallnspe - Z <br /> Date9r��"* f'f <br /> t� tees gyp, 4524 414Mt' "°. <br /> I 'b C 11a b Tete' �pcttoll oMSE <br /> Aet CtY 8e E <br /> 2404' 4� oa��� <br /> ptict��n for bV 3�quSY' yiTo e.. D GEtV <br /> gtIn SG zes' lto0 A t�SN <br /> 4 61 <br /> GIC marts' ct�4ieb . $. M'�to <br /> adtttot%$ Co gets aSl NMeu�;pt <br />