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nom• - � . _ ., EMCON No.f.-939-G3.�/y� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �,�/C.�a,_--s'' �=° -- �,I f-��t.4._c�-.1"��_ '"'� �-�J�J• zs.3--o,3 t�--I r'J Job Address Corral _Hollow Sanit�ry `Landfill._ city Tracy Lot Size PM Owner's Name Joaquin Address P one L2-09) 468-3066 Consultant: E ONIIASSOCiates 921 Ringwood Ave, an JJose, A. 95131 (h408 275-1444 Contractor—Driller: e e elo ent Address 220 North East St. oodTandnseNo. C57-283326Phone 1916)662-282 9 TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUiMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I DISTANCE TO NEAREST: SEPTIC TANK _NA SEWER LINES _.- NA�_ DISPOSAL FLO.NA PROP: LINE 25`-300` FOUNDATION -NA_.._ AGRICULTURE WELL -NA-_ OTHER WELL-U-`— PITS/SUMPS NA k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Wefl Excavation Diof Well Casing 1 n" Sty±�,._ a. ❑ Domestic/Private Gravel Pack Tracy Dia.Type of Casing PVC Specifications J i r Public f_-] ether ❑ Delta Depth of Grout Seal 250`-300` Type of Grout Volclay, I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Cement Bentonite Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYQk,OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer �!. available within 200 feet.) Installation wit Residence— Commercial_ Other Number of living units: IM. Number of bedrooms I Character of soil to a depth of 3 fee . er table depth SEPTIC TANK ❑ Type'/Mfg Capacity No. Compartments r -� PKG. TREATMENT PLT, El �I Method of Disposal Distance to nearest: Well ation Property Line ' LEACHING LINE ❑ No. & Length of lines length/size FILTER BED ❑ f)istance t . rest: Well Foundation Pro Line SEEPAGE PITS I Depth Size Number 1 SUMPS ❑ Distance to nearest: Well Foundation - 1 Property Line OSAL 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, ar, rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall n employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signatul hall certifies the following': "I certify�that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensi_. tion laws of California." The applicant must call for'quired inspections. Complete drawing on reverse side. I Signed for EMCON Associates Title: NA Date: 4/4/88 f. i OR DEPARTMENT USE ONLY Applicat' cepted by ��1 �wn _ q auhov,.,� _ Date„ 4" b Area 1 Pit Grout pection by I�1�� a �� L Final Inspection by Date L�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi, 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk,, CA 95201 t .I. E INFO DUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. C { EH1a261REV.tik51i� `��, ®� 13 �q {� A