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I • APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRIL�f 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. South of Job Address Corral Hollow Road City___Tracy Lot Size – PM — --- Owner's Name Connolly Ranch, Inc. Address P. O Boa 811 Tracy, Ca Phone (209)835-7915 1780 Vernon Street Contractor PC Exploration Address Roseville, CA 95678 License No. 265556 Phone 916 783-97 33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑Four monitor wells PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER RI in S1W corner of DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Section 25 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _. n H Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation 10 to 12�� Dia. of Well Casing �! _ 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications cement— I'] Puhlic 1-1 Other fl Delta Depth of Grout Seat o—bII—de-te.rminedype of Grout bentonite_ I I Irrigation _-_ Approx. Depth I I Eastern Surface Seal Installed by__P_C__EaglosatloII- ---- Repair Work Done IJ Type of Pump H.P. _ State Work Done _ Well Destruction ❑ Well Diameter __ Sealing Material (top 50') - -- Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundati rop i LEACHING LINE ❑ No. & Length of lines al LLgth/size------ FILTER siz — - FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size__ _—_—_— Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL 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, and rules and regulations of the San Joaquin Local Health Diltrict. Home o%gner 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 ��+ D� /�tKG�M Title: �'rw_ --rn��a1 Date: FOR DEP ENT NLY Application Accepted by _—_ Date / Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: -- C) 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH � EH 13 24 IREV.i i x 51 FH 14 26