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i Z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT all TTQ 1 E. HAZELTON ON AVE. STOCKTON ! 160 , CA a 1C Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 1 1 1087 (Complete in Triplicate) ENVIROMENTAL HEALTH Application Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workjhEpMg$5WVrwt 5pplication 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. '',,jQ 3 lI" Job Address 5999 Escalon—Bellota Rd. city Linden Lot Size PM Owner's Name Foster Farms Address 2 857 Geer Rd. Turlock Phone ((� �urviance Drillers Drill!ng Corp. Contracto Address P#. 10• BOX 64, L1ndggnse No. 377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL F-1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER ❑ 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public ❑ Other Cl 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 Sub H.p, 7g HP State Work Done install new pump l Well Destruction ❑ Well Diameter Sealing Material (top 501 new well Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION I I INo 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 Al SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line ( DISPOSAL PONDS ❑ f 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_oLCalifornia." The �Plicartt m t call for it re ui d inspections. Complete drawing on reverse side. Signed�c Tale: Corp e Secretary Date: 7/31/87 FOR DEPARTMENT USE ONLY Application Accepted by Date rea Pit or Grout Inspection by ate Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH1321(REV.1/ns) " EH 14-29