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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 7� S 445 N SAN JOAQUIN, PHONE (209)468-3420 W P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Regulations of San Joaquin County Public Health Services. both are Corral Hollow Road Trac , CA ECJ Gallo Winery, P.O. box 1130 Modesto, GA Lot Size/Acreage -_— City - Job Address racy; P — Address 1111U0_L_D1ay__St Gak n �•s Phone 510 27 — 111 Owner's Name rT c DOE 1780 Vernon Street Contractor PC ECloration Address Roseville _fid—..�.Z-$--.--License No. ��+5556 —Phone 1 783-973 TYPE OF WELL/PUMP•. NEW WELL 11 WELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ OTHER K Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ p ory borehole SEWER LINES _ DISPOSAL FLD. � 8f}. 0 DISTANCE TO NEAREST: SEPTIC TANK __ _ FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing �+t n Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Cement/bento to Type of Casing poC_--- Specifications f.l Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Variable Type of Grout I'1 Public 11 Other (-I Delta PC Exploration _ I I Irrigation __ Approx. Depth 1 I Eastern Surface Seal Installed by of Pum H.P. _--- ---------- State Work Done — Repair Work Done Ll Type p - Sealing Material & Depth Well Destruction O Well Diameter - Filler Material & Depth f Depth — TYPE OF SEPTIC WORK: NEW INSTALLATION 1 ! REPAIR/ADDITION I Di STRUCTiON I I availablerw thin 200 feetc system .) if public sewer is l t" Installation will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms_. _ Water table depth � Character of soil to a depth of 3 feet: — No. Cpm C SEPTIC TANK ❑ Type/Mfg _ Capacity_ ,�y N PKG. TREATMENT PLT. ❑ Distance to nearest: Wel! Foundation Propert Total length/size LEACHING L ❑ No. & Length of lines — — CI Distance to nearest: Well_ F eundation _— Property Lina ` FILTER BED — Size Nut ber;'WELL' SEEPAGE PITS I I Depth ---- Property Line SUMPS LI Distance to nearest: Well _ Foundation_.. DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be dono in accordance-4th 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 .n the performance r 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 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. Section Leader Date: 1/5/94 Signed X .�L� �Ctiti�- _ Title: FOR DEPARTMENT USE ONLY ��7] ✓�_ 7 T.f /� Area Application Accepted by c - __ C.)ate Date Pit or Grout Inspection by ---- Date Final Inspection by Additional Comments: _ Applicant - Return all copies to: San .Joaquin County Public Health Services Environmental Health Permit/Services. 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE CK RECEIVED FiY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH EH 13-24(REV.I/As) EH 71.26 - �"�