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AN JOAQUIN LOCAL HEALTH DISTRO 1601 E. HAZELTON AVE., STOCKTON, CA AMA - ._Telephone (2091 466-6781 Z.lgPERMIT EXPIRES 1 YEAR FROM DATE ISSUED �gaa (Complete in TripliFate) On, Application is hereby made to theSan Joaquin Local Health District for apermit to construct and//or iinstall the work herein q � is made in com liance with San Joaguin Coun Ordinance No.549 for sewsga or No. 1862 for well/ um and the Ruleb�L'1`31� #� ` n Local Health District. M 1 Job Address Corral Hollow & SPRR City Tracy Lot Size 45 acres PM 95209 Owner's Name Beck Development Address 3114 W. Hammer Lane, Stockton Phone 209 957-033 95678 C57 & C61 Contractor All Terrain Drill:kU,ss 2789 Liberty Ln, Rosevilk4nse No. 437836 Phone_771-0222 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 91 Monitoring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 300 FOUNDATION AGRICULTURE WELL OTHER WELL 300' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LlIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing rr ❑ Domestic/Private 6 Gravel Pack ❑ Tracy Type of Casing SCh. 40 PVC Specifications fl Public 11 Other n Delta Depth of Grout Seal Type of Grout Cement LBentc nite I I Irrigation _,Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. —---------I State Work Done _ Well Destruction ❑ Well Diameter _ Sealing Material (top 501 Depth Filler Material (Below 501 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 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 ❑ 1 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." The applicant Oust call for all luired it pections. Complete drawing on reverse side. 7 / F /�-- / Title: GC1L �)Z",l 7 Date: `0 Signed Z o �/r� A•1• Dr FOR DEPARTMENT USE ONLY tee Application Accepted by Date ... 2 $� Area_ I 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 K RECEIVED 9y DATE PERMIT'NO. INFO R III 1}24(REV.r i x w EH 1426 ��3 ) _O� 3ys / Frs $$-Zq 7