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APPLICATION FOR PERMIT .N JOAQUIN LOCAL HEALTH DISTR* 1601 E. HAZELTON 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. Job Address Gallo Ranch, Corral Hollow Road City Tracy Lot Size PM Owner's Name E & J Gallo Winery AddressP•O. Bog 1130 Modesto, CA 95333 Phone 209 579-3373 1780 Vernon St. Contractor PC Exploration Address Roseville, CA 95678 License No. 965556 Phone(916)782-973 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER R Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1019 Dia. of Well Casing 4.5 in. lli Domestic/Private & Gravel Pack ❑ Tracy Type of Casing PVC Specifications F1, PUblic Cl Other 1-1 Delta Depth of Grout Searo be determine(type of Grout Cement _ 1 1 Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by PC Egploration bentonite _ Repair Work Done 0 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 1 1 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 Foundation Property Line LEACHING LINE ❑ No. & 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 ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county',o4dtl1$twesiestate laws, and rules and regulations of the San Joaquin Local Health District. �,r 3 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thls�peistutjs,M4, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's t(i}i, Pr� cgrltting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ pwTn su lec oikm>�rt's compensa- tion laws of California." PLI H' The applicant ust call for all required inspections. Complete drawing on reverse side. 4j1�;�.0 1, n r0L�J{'), tTt� y M Signed X . V Yru u i,� ATitle: Section Leader Date: L' r� � wsL--L, 10 30-`f MENT USE ONLY DEP / �j Application Accepted by 5: Date ( / /Z�// 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^/ _,5 6— FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. v INFO �' /^CyAASHH + EH 13-24(REV.1i N5) ("�) D(/ `•'v �� Z !/ /`moi`�� EH 14-2e