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APPLICATION FOR PERMI " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ° ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-34,20 O C T 4 1a.910 P O 80X, 2009; STOCKTON, 'CA 95201" ENVIRONMENTAL HEALTH PERMIT EXPIRES I YEAR FROM-DATE ISSUIM PER'N'IT/SlERVIl,ES (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 with San Joaquin County.Ord inance No. 549,and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 50 W. Turn r Road City Lodi ____ Lot size/Acreage N/A Owner's Name AT&TAddress 11- W_ Turner. Rria.ji Lnii ,SA Phone - 9110 3429 Longview Drive 306291- Contractor Be l i k Drilling Address____North_ Highlands, CA License No. C-' 57&SC-6#hone 916 485-07 TYPE OF WELL/PUMP: NEW WELL 4. WELL REPLACEMENT ❑ DESTRUCTION Li//Out.,of Service Well Gl MW-3 PUMP INSTALLATION ❑ SYSTEM'REPAIR ❑ OT�H❑ER ❑1 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 1�100 SEWER LINES 600 DISPOSAL FLD. N ^ PROP. LINE 50 FEET FOUNDATION —350 AGRICULTURE WELL 250 OTHER WELL PITS/SUMPS 500 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f1 Industrial ❑ Open.Bottom [3 Manteca pia. of Well Excavation Dia. of Well Casing n El Domestic/Private ® Gravel Pack- �/A 0 Tracy Type of Casing Sch. 40 PVC Speoilicaiions 0•UZ-in slat iR awi ie Moni tori ngl i Other n Delta Depth of Grout Seal about 30- ft- Type of Grout_ bentoni te- I I'Irri)ation 4..Approx, Depth I I Eastern Surface Soul Installed by tremia cement Repair Work Done 0 Type of Pump H.P. State Work Done Y Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION'f I DESTRUCTION I I (No septic system permitted if public rawer is available within 200 feet.) Installation will serve: Residence Commercials____ Other " Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Typ0Mfg Capacity" No. Compartments li TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 8 Length of lines Total length/size FILTER BED is Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS I I Depth Size Number SUMPS 0 "Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ . I hereby certify that 1 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 Canities the following: "I certify that in the performance of the work fpr 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this peri 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 �_ e �6 {c� �. Title: _ __ESE Staff Geologist Dafe': 10-2-90 Emilio Gonzalez, Jr. , CEG FOR DEPARTMENT USE ONLY Application Accepted by ^^'�'� Date �r�qb „ _ Area T "_�ICbT " Pit or Grout Inspection by 4" "Date �/ Final Inspection by °�r T Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health € Services. EnvironmentalRHealth Permit/Services, 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 `r FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO i s 1 13-24 1111 1/"51 _ X ��.