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APPLICATION FOR PERMIT O <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA AUG 2 8 1987 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED XNVIROMENTAL HEALTH <br /> (Corriplete in Triplicate) PERMIT/SERVICES, <br /> 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 <br /> 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 <br /> Local Health District. W, U­k�— <br /> Job Address 59991Escalon-Bellota Rd City Linden Lot Size PM <br /> Owner's Name Foster Farms Address 2 857 G-eer Rd Tu l0 k Phone <br /> Contracttl ani Drillers Drilling Corp. Address P- 0. Box 64 LindenLicense No. 3— 3 Phone 887-3554 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Dt SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL• PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing, <br /> E <br /> asing- <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i`} Public Cl Other F Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _..Approx. Depth I I Eastern Surface Seal installed by _ <br /> Repair Work Done ❑ Type of Pump sub H.p. 7''HP State Work Done instal I new Ig p in <br /> Well Destruction ❑ Well Diameter Y Sealing Material (top 50') new Well <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i-1 REPAIR/ADDITION 13 DESTRUCTION I I (No septic system permitted if public sewer is <br /> .r <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— "Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well HFoundation Property Line <br /> SEEPAGE PITS C I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> biSPQSAL PONDS .b <br /> 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The pplicant c fo alreq 're�inspac;ions-, Complete drawing on reverse side. -, <br /> Signed Title: Corp. Secretary Date: 7/31/$7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by L& Date Are <br /> Pit or Grout Inspection by Date Final Inspection by Date _ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 d Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> + EH13.21(ftEV.tiK5) `:>>S00 <br /> EH tt-2a <br /> I <br /> 1 <br />