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r r � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) �P`T ff 7-7U 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 made in compliance with San Joaquin County Ordinance No. .554,99ffor sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health district. Job Address 1.3 mile north of Flood Rd, City Linden Lot Size PM 4001 West of Escalon Bellota Rd. Owner's Name Foster Farms Address 2857 Geer RrTijrI qr�k Phone 377923 ContractorPurylance Driller,4,dPA}lying Corp. P. O. Bo ef�jpo.Linden, Phone887-3554 TYPE OF WELL/PUMP: NEW WELL Z 13rrr. veWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 10 n X Domestic/Private ❑ Gravel Pack ❑ Tracy '. Type of CasinglOcia Rai Well Specifications 10ga � f7 Public N Other 17 Delta Depth of Grout Seal 8.0° of 14" Type of Grout Comment I I Irrigation 5O— pprox. Depth 12 Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filter Material IBelow 501 TYPE EPTIC WORK: NEW..INSTALLATION ("I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve. Resi Commercial_ Other Number of living units: Number of Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Prop ne LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 l Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line 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 mannir 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." i The applican st call for ired inspections. Complete drawing on reverse side. Signed X Title: President Date: 7/2Q/87 FOR P4PARTMENT USE ONLY Application Accepted by _ p Date Area ly v 41 Pit or Grout Inspection by A Dat Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7184 ❑ Tracy -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK if CASH RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.I/H 5) EH 14-26 !!r O I