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5 . rr APPLICATION FOR PERM i VE ,fie SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EH V I RONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 OCT 4 19110 P O BOR 2009r, STOCSTON, CA 95201 ENVIROWENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM UATE ISSUED PERM 1T/Sr"RVICES (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 Ordinance No. 549 and 1862 and the Rules and Aegulations of San Joaquin County Public Health services. Job Address 110 W. Turner Road City Lodi Lot Size/Acreage NZA Owner's Name AT&T Coinmuni Cati onS __ __ _ Address .110- W. Turner Road, Lodi Phon.(20MI57-9110 3429 Longview Drive 306221-�l contractor BeYI i k Dr71 l:i ng Address N4rl2 H j ghl and.S- CA__ license No. � 5 — Phone 916485-62 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well -C:1 MW-1 MW-2 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CIM Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 800 SEWER LINES 350- _ DISPOSAL FLD. Nf/A PROP. LINE ._20_ (FEET) FOUNDATION 20 AGRICULTURE WELL ,ADD- OTHER WELL 300 PITS/SUMPS M INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0:Industrial ❑ Open Bottom ❑ Manteca bia. of Well Excavation 12 i nch Dia. of Welt Casing f:)0Oomestic/Private IM Gravel Pack Ll Tracy Type of Casing SCh. 40 PVC Specifications0—Q2 1nCh. 51 t im P,ioieMon i tori ng ri Other R Delta NSA Depth of Grout Seal ab0iJt .10 ft Type of Groutbentoni Je- I I Ifrigation 4-ri-Approx. Depth I I Eastern Surface Seal Installed by tremi a Cement Repair Work Done 0 Type of Pump H.P. State Work Done_. Well Destruction ❑ Well Diameter Sealing Material, 6 Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.1 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. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED n Distance to nearest, Well Foundation Property Line SEEPAGE PITS 11 'Depth Size 4 Number SUMPS LI .Distance to nearest: Well " Foundation Property Line DISPOSAL PONDS G 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: "1 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 canifies 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 Title: ESE Staff Geol ogi St. Date': 10-2-90 Emilio onzal ez, Jr�./ CEG FOR DEPARTMENT USE ONLY ,1 Application Accepted by " -' Date Z6_1_11h U Area 7 �� Pit or Grout Inspection by J Date 11146 - Final Inspection by , Date It Additional Comments: M �• f !i>7 1 �1 C 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 1. DATE PEflMlT'N0. . EK 13.24(REV.r/esr fM;1-2a r c '