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APPLICATION FOR PERMIT 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. south of Job Address Corral Hollow Road city Tracy Lot Size - PM Dept. of Fish and Game, Region II Owner's Name State of California Address 1701 Nimbus Rd., Rancho CordovarPhCA (916)355-701 95670 Contractor PC Exploration Address 1780 Vernon St. Rose eQ& 265556 Phone (916)783-9T 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CX Monitor W-25 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 SPECIFI�/� IONS 4 �n L] Industrial El Open Bottom [I Manteca Dia. of Well Excavationis--— Dia. of Well Casing 11 Domestic/Private L1 Gravel Pack ❑ PVC SpecificationTracy Type of CasingBement/bentOn to FI Public [-I Other n Delta Depth of Grout Seal 26.8 Type of Grout I I Irrigation -- Approx. P1rox. A Depth 1 I Eastern Surface Seal Installed by PC Exploration Repair Work Done L7 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 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 L 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 District. Horne 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 or all required inspections. Complete drawing on reverse side. ` q Signed X /[Iv UiCr` �L G(M�G�✓1 �` Title: ?, ° .� J ` Date: .y FOR D RTM E ONLY r- i Application Accepted by �i Date ' y Area `J V Pit or Grout Inspection by Date Final Inspection by / , Dated Additional Comments: L<1_04 ' f r L�av� z r� � �G� �r` " ` � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant a 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 REMITTEDC H RECEIVED BY DATE PERMIT'NO. INFO . EH 13-24(REV.1/85) I �/� .�f, ? EH 14-28 "1