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• EMCON No. 939-03.,3T/g4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �» "" 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYE R 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 Sanitandfill City Tracy Lot Size PM Owner's Name rounj Address Phone — 1066 Consultant: EM ON Associates1 1921 Ringwoo Ave. San dJosa,CC . 95131 (408 27 - 444 Cont�toer'Water Qevelopment Address 220 North East St. 1lanense No. C57A. -283326Phone 916 662-28 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [X DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES NA DISPOSAL FLD.NA PROP. LINE 25 -300' FOUNDATION nA AGRICULTURE WELL _A_ OTHER WELL 25 t PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 all & 211 Dia. of Well Casing r yi X 911 ❑ Domestic/Private 19 Gravel Pack IN Tracy Type of Casing PVC Specifications ("1 Public Cl Other Cl Delta Depth of Grout Seal 250'-300' Type of Grout Vol clay, I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Cement/Bentonite _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 1"14R OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION=ZF77 ermitted if public sewer ' /feet.)Installation wil Residence_ Commercial OtherNumber of living units: Number of bedrooms Character of soil to a depth of 3 fee . epthSEPTIC TANK ❑ Type/Mfg Capacity . ents PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: :Well ation Property Line LEACHING LINE ❑ No. & Length of lines length/size FILTER BED ❑ Distance t rest: Well Foundation Pr-6pecty Line SEEPAGE PITS I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line OSAL 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. 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 required inspections. Complete drawing on reverse side. Signed r for EMCON Associates Title: NA Date: 4/4/88 �v 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 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a EH 13-24(REV.1/n 5) EH 14-2e