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F!EA APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,'aSTOCKTON, CA Telephone (209) 466-6781 `j�'7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JkU:N" `? {Complete in Triplicate} 4 � l Application is:hefeby'made to the San Joaquin Local Health District for a permit toconstructand/or install ih�wvrjs�fie a:rY ed! ftiUglication is made 1n compliance with San Joaquin County Ordinance No.549 for sewa a or No. 1862 for well/pump nd t R i b(�� e Joaquin Local Healfh District. Al° nr�w � '� -(� 0931 Job Address l l -' north of Flood Rd city b Lot Size k PM ' 400' west ,of Escalon 'Bellotat Rd. 7 i - Owner's Name. Foster Farms Address 2857 Geer Rd., Turlock Phone ContractoFui'yiariCp_ Dr111Q Address '. 4. Box 64rkLlndencense No.377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES `-"`DISPOSAL FLD PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL, PITS/SUMPS INTENDED USE--TYPE OF-WEL-L P_ROBLEMAREA--CONSTRUCTION-SPECIFICATIONS- '�"' a' v i � Manteca Dia. of Well Excavation 10'r Dia. of Well Casing 10" 11 Industrial 171 Open Bottom �, 9 _ X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ kin Well Specifications I0yu.43 e I�1 ❑ Public 5 Other. ❑ Delta Depth of Grout Seal 100 of Iq et Type of Grout Cement ❑ Irrigation 6-8—O4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done F Well Destruction © Wei! Diameter Sealing Material (top 50') j Depth Filler Material (Below 50') 1 l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ;available within 200 feet.l Installation will serve: Residence_ Commercial Other y j 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 1 ; Distance to nearest: Well Foundation � Property Line r v k LEACHING LINE ❑ No. &Length of lines - Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line .p SEEPAGE PITS ❑ "Depth Size Number --SUMPS- ❑,,,rDlstance to-nearest:._ Well. Foundation -Property,Line _ M DISPOSAL PONDS' ❑ I hereby certify,,trhat-l-have i andha -prepared-this-thisIlia the work will-b-e done-in'-accordance-with'San Joaquin county ordinances, state laws, and rules and regulations of,the San Joaquin Local Health District. Home owner or licensea' gent'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."Contractors 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." ' mak ,;° 1 The applicant must call f a quired inspections. Complete drawing on reverse side. , 341 r,. Signed Title: President Date: 6�17/8 7 DEPARTMENT USE ONLY Application Accepted by Date 6Q Area r i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ 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 41 FEE OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"ND. INFO CASH ft + EH 13-241REV.i/65) - � �— �� EH 1426 L ��..•JJJ '�- 111