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APPLICATION FOR PERMIT SAN .,OAQUIN COUNTY PUBLIC HEALTH S,,RVICES ENVIRONMENTAL HEALTH DIVISION ' 1601 E. HAZELTON AVE. , PHONE (209)468-3420 • P O BOX 2009, STOCKTON, CA 95201. P EXPIRES 1 YEAR FROM DATE ISSUN) (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 vith San Joaquin County Ordinance No. 119 and 1862 and the Rules and Regulations of San ' Joaquin County Public Health Services. — .fob Address 50 W. Tu a City Lot Site/Acreage N/A ' Owner's Name _A_T&T Communications _ Address Phone - 2110 3429 Longview Drive 306291- Contractor Beyl i k Dri 11 i n Address North Hi hl ands CA License No C-57&SC-64one(916)485-0Z92 TYPE OF WELL/PUMP NEW WELL W WELL REPLACEMENT ❑ DESTRUCTION ❑' /Out of Service Well ❑MW-3 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑(1) Monitoring Well DISTANCE TO NEAREST SEPTIC TANK .1,100 -— SEWER LINES 600 DISPOSAL FLD N/A_ _ PROP LINE 50 FEET FOUNDATION350 AGRICULTURE WELL 25Q- OTHER WELL-10— PITS/SUMPS 500 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Cann n Domestic/Private ® Gravel Pack N/A ❑Tracy Type of Casing Sch. 40 PVC Specifications 0•�2--in slot ' i�F4rblis Moni tori ngn Other n Delta Depth of Grout Seal about 30_ f:L-- Type of Grout Qntonj Je- I I Irrigation 4L Approx Depth I I Eastern Surface Seal Installed by treml a Cement Repair Work Done U Type of Pump H P State Work Done Well Destructon ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permuted of public sewer is available within 200 feet 1 ,• Installation will serve Residence— Commercial Other Number of roving units Number of bedrooms Character of soll to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line ' LEACHING LINE ❑ No ✓k Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 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 1 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 tea _ Ma sem-- Title . ESE Staff Geologist Date 10-2-90 Emilio Gonzalez, Jr. , CEG FOR DEPARTMENT USE ONLY 1 Application Accepted by Data Area ' Pit or Grout Inspection by Date Final Inspection by Date MAddnional Comments Applicant — Return all copies to. San Joaquin County Public Health ' Services, Environmental Health Permit/Services 1601 E Hatelton Ave P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERM17 NO EH17244REV tins! • EH 4 2$