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APPLICATION FOR PERMIT ter„ SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA L : Telephone (209) 466-6781 X PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 1 4957 (Complete in Triplicate) FNViR()MEAL HEP+qq(-jH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herFF 'VS.ErM�.4s ation is i 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. 010 Job Address 5999 Escalon—Bellota Rd. city Lind n Lot Size PM Owner's Name Foster Farms Address AUR 2857 Geer Rd Tur10cW.ne Purvlance Dr{Iters Drilling Corp. Pe O s Box 64, Linde 377923 Phone Contractor Address nLicense IVo. 887-3554 TYPE OF_WELL/PUMP: -NEW WELL O _ _ WELL REPLACEMENT ❑ DESTRUCTION 1-1 PUMP INSTALLATION ❑ SYSTEM.REPAIR. ❑ OTHER ❑ r,. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t ,DISPOSAL FLO. PROP. LINE { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout -- I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump subH.P- 71-hl:) State Work Done install new pump in Well Destruction ❑ Well Diameter Sealing Material (top 50') new well Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other s, 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 r' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well f=oundation Property Line 1 � 4 SEEPAGE PITS II' Depth Size - Number SUMPS Cl Distance to nearest: Well Foundation `Property Line r! 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. 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." Th app cant-must call for all r9 uired inspections. Complete drawing on reverse side. Signe _.._-., Title: Corp. Secretary ._.-. Date: 8/6/87 FOR DEPARTMENT USE ONLY / /#-1 Application Accepted by /' Date 0.57�L rea Pit or Grout Inspection by Date Final Inspection by ' I 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. D + EH 13-241REV.1/14SY EH 14.26 (�