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APPLICATION FOR PERMIT ' SAN JOAQUIN .LOCAL HEALTH DISTRICT 1601 E. HAZEL—I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �/q �(�" �.lpn is Application is hereby.made to the San Joaquin OLdinance No.549 for sewage or permitHealth District for a to 1862 for weconstruct llldpuomlp and the �Bn Regc + of hi aquin made in compliance with San Joaquin County F/� l%j�. CYr Local Health District. lCity Ripon Lot Size PM 311 W. 1st Street Job Address 95366 S h' 1 311 W. 1st Street Ri on CA Phone(209)599-2108 l Owner's Name City of Ripon Address _ __ �_�� (714)- — ,- La ne_Environmental N 1.60,1$ 'Val� ey"t B1v_d, „; 355'=3.355 +k . . y - —. 457. 0.9 Phone I "s Address` Fontana,. C& _923-35_' License No. _._� Contractor - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 l DISTANCE TO NEAREST: SEPTIC TANK 50 t SEWER LINES T 50' DISPOSAL FLD. NA PROP. LINE > FOUNDATION } 501 AGRICULTURE WELL NA OTHER WELL NA PITS/SUMPS NA I j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4-inch Dia. of Well Excavation —1nC Dia. of Well Casing I] Industrial El Open Bottom ❑ Manteca PVC Specifications 4Type of Casing ❑ Domestic/l Private ❑ Gravel Pack Ll Tracy 1-1 Public rXOther Monitor ilig Delta Depth of Grout Seal 201 & 90 t — Type of Grout e I A rox. Depth i I Eastern Surface Seal Installed by I ! Irrigation — PP State Work Done— Repair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Well Diameter Sealing Material (top 501 .11 Depth Filler Material (Below 501 irmW 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIAQDITION t DESTRUCTION l 1 stem pe anvailablerwthin 200 feet.) if public sewer +s Installation will serve! Residence— Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Np. Compartments t SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS L71 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 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 of California." E The applicant must all for all required inspections. Complete drawing on reverse side. I Title: Plant Manager Date: Signed X DE NT USE ONLY Date — Ar a Application Accepted by —_ __ ` Pit or Grout Inspection by Date Final Inspection by Date ` Additional Comments: ❑ Stk 466.6781 17 Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 635 6385 Applicant- Return all copies to: Environmental Health PermiVServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY [SATE PERMIT NO. INFO �^ ^ c ♦,EH 13-24(REV.I/H 5) 3 �J 4 - O �� ?5 EH 14-f 1 Applicant is Nestle Foods Corp. , Owner is City of Ripon. Agreement is attached.