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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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. F Assessor #177-100-22 2467 Ep, French Camp-4Rd French Camp 4251-3231 Parcel c-2 Job Address City Lot Size PM . ace Tomato Co. 2771 E. French .Camp Rd 982-5691 Owner's Name Address Phone Contractor's Name Clark Well License No. 371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L SYSTEM REPAIR ❑ OTHER 11t j DISTANCE TO NEAREST: SEPTIC.TANK 150' SEWER LINES .DISPOSAL FLD. 15O PROP. LINE 15 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — `INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS KI Industrial ❑X'Open Bottom ❑ Manteca Dia. of Well Excavation 2611 Dia. of Well Casing tt El Domestic/Private 1&Gravel Pack ❑ Tracy Type of Casing StEEZ _ Specifications .250 r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal SO Type of Grout ❑ Irrigation --Approx. De�th ❑.Eastern ace Seal Installed by Clark Repair Work Done ❑ Type of Pump I UT�11n8 H.P. 1 U State Work Done instaii Well Destruction ❑ Well Diameter Sealing Material {top 501 F Depth - Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION ❑ Wo septic system permitted if public sewer is available within 200 feet.) v Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Z SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED k ❑ Distance to nearest: Well Foundation Property Line e SEEPAGE PITS ❑ Depth Size Number SUMPS t ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 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. t" Home owner or licensed agent' tura 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 suc nner as t become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I fy that i rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C ifor ia." ;;;' � - The app lica, t c f I r /red i;s ons. plate drawing on reverse side. Signed Title: VP-Clark Well Date: 4 Oct 1985 c FOR DEPARTMENT USE ONLY C Applicatio cepted by Date O -Area PitoGrout i pection by ate I0-AV9K Final Inspection by�Jc��+►• ate Av�s`�� F _ _ Additional Comments- 0 Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 < 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 CK RECEIVED BY DATE PERMIT NO. INFO CASH r + EH 1324(REV.10!831 $J^I7,Q$ EH 1426 �� C?O / O-•� TS 5-A-�, '