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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT T 1601 E. HAZEL ON~AVE., 'STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 22510 E. Highway 4 Stkn 600 Acres • City LotSize pry Owner's Name Ace Tomato CO. Inc Address 2771 E. French C!lmp Rd. F . l - Contractor Hildebrand Const . Address P•0. 66003, Stoekto ense No,_X115phorie 862 46 2 a' 6 Phone 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ f 'fir f' DISTANCE TO NEAREST: SEPTIC TANK _ALS 1 'SEWER LINES DISPOSAL FLD. Q PROP: LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS", t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Wel! Excavation •-- -- --Dia.-of Well Casing ., L1Domestic/Piivate 0 Gravel Pack L1Tracy Type of Casing..- � k Specifications ,C'1 Public H Other D Delta Depth of Grout Seal i Type of Grout I 1 Irrigation --Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done C Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') ` l Depth Filler Material Welow 50') i TYPE OF SEPTIC WORK: NEW INSTAI-LATION;K, REPAIR/ADDITION�IJ �OESTRUCTION I I (No septic system permitted if public sewer is available within 200-feet, Installation will serve: Residence Commercial Other �a Number of living units: Number of beddfoms� "* r` Character of soil to a depth of 3 feet: L "� ,A Water table.depth Type/Mfg SEPTIC TANK ❑ Ta,..f / Capacity :� �, No. Compartments -PKG. TREATMENT PLT. ❑ t. �" Method of Disposal pig Distance to nearest: Well Foundation� Property Line f t Y. JS "ell ¢ . LEACHING LINE ❑ No. & Length of lines a @v :lam �" � �` b Total length/ !e FILTER BED ❑ distance to nearest: Well t Foundationt .moo Property Line [ [� SEEPAGE PITS 1-1 Depth \Size{' ' Number SUMPS L7 Distance to nearest: Well Foundation Property Line .DISPOSAL PONDS ❑ J I hereby certify that t 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 work'-man's compensation laws of California."Contractor's hiring or sub-contracting signature certipermit ties the following: "I certify that in the performance of the work for which this it is issued;I shall employ tion laws of Californ' p P Y persons subject to workman's compensa- The applicant u call for all quired inspections. Complete drawing on reverse side. Signed X k _ f � Title: ate:BI T ILa RraN� FOR~DEPARTMENT USE'64CY {� Application Accepted by Date Area v Pit or Grout Inspection by Date Final inspection by Date Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 83 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C ) WO ASH RECEIVED BY DATE PERMIT'NO. EH 13-24 EH 14-29 `� �' a�i ��✓ r