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0 APPLICATION FOR PERMIT II* 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. Job Address Corral Hollow Road City S. of Tracy Lot Size — PM — -- State of California Address Deft. of Fish and Campion Uone (916)355-7010 Owner's Name 1780 1701 Nimbus Rd., Rancho Cordova, CA 95670 P. C. Exploration Address0erWn St., Roseville, C�ieN`L6Aig. 265556 Phone (916)783-97:13 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION 11 Monitor Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P:PROLR FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !{ 1/2u Ll Industrial FJ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing4i Type 1.1 Domestic/Private ❑ TGravel Pack ❑ Tracy YP of Casing- PVC Specifications _ (1 Other n Delta Depth of Grout Seal 20.2 g t Type of Gr ut ceme. I'I Public �3euton to I Irrigation __ Approx. Depth l I Eastern Surface Seal Installed by PC Exploration - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 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: 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 LI 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 Di§trict. 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, 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. 1?' c L P c C6—_ Date: I -/° ' 9 Signed X I t V (!nom r- - /Vn�CAi1 e Title: FOR nR4TM1W1eTONLY _Application Accepted by Date 5 T J Area � Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ET 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 SCK RECEIVED BY DATE PERMIT NO. INFO CASH ♦ EH 13,24(REV.riH5) EH 1t-26