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EMCbN No. 3�-b3. j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTi 1601 E. HAZEL T ON AVE., STOCKTON, CA 4 Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) , i„ y AUH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein,T 'a' tion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Aegulations of the San Joaquin Local Health District. Job Address Corral 'Hollow Sanitary I andfill city Tra _v_ Lot Size PM Owner's Name fount_ nT au1n.� Address _ � Phone Consultant: E ON Associates 1921 Ringwood Aver. Wan A. 95131 (408 27 - 44 c Contractor *Water Development Address 220 North East St. License No. C57-283326Phone 916 662-28 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IX DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES NA DISPOSAL FLD. NA— PROP. LINE 25 -300' FOUNDATION RA AGRICULTURE WELL OTHER WELL 25 r PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Inn & $" Dia. of Well Casing u & pit ❑ Domestic/Private N Gravel Pack (X Tracy Type of Casing PVC Specifications ("1 Public n Other n Delta Depth of Grout Seal 250'-300' Type of Grout Vol clay, _ I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Cement/Bentonite _ Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYR OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer 's-� available within 200 feet.) Installation wil Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fee . er table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. & Length of lines length/size FILTER BED El Distance t rest: Well Foundation Pr Line SEEPAGE PITS1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line OSALPONDS ❑ 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 District. 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." Theapplicant must call fo required inspections. Complete drawing on reverse side. Signed for EMCON Associates Title: NA Date: 4/4/88 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ♦ EH 13-241RE'V.1/x 5) EH 14-28