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4 � I <br /> APPLICATION FOR PERMITy �nrn <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA AUS $ <br /> Telephone (209) 466-6781 W7 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVINUjMENTAL HEALTH <br /> (Complete in Triplicate) k ERMIT/SERVICE$ <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. tt <br /> Job Address 5999 Escalon-Bellota Rd. Cites Lind}Size PM <br /> Owner's Name Foster Farms Address 2857 Geer Rd, , Turlock Phone <br /> Contractor PuMance Drillers Drilling COM- AddresFo O.Box 64PLi.ndenp__CUcense No. 377923 Phone 887-3554 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _ FOUNDATION . ..AGRICULTURE WELL. OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ 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 0 Type of PumpSLlb H.P. 72 rip State Work Donenstall new P In <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 new well <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 1 lNo septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other t <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 /> t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation + Property Line <br /> SEEPAGE PITS I I Depth 4 Size Number , <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL'PONDS ❑ <br /> 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 <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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> Thapplicant 4s, call pfod inspectiont;. Complete drawing on reverse side. <br /> Sign Title: Corp. Secretary Date: 8/26/87 <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date Q+"" " "� Are � <br /> Pit or Grout Inspection by Date Final Inspection by Date�� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 13 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEEO AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY { DATE PERMIT'NO. i <br /> a EH1314tNEY.I/r51 t.�a �^ $1•�(3 �.� <br />