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• r r. : APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 11 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. 1811 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 11 South "A" Street City StOCkton lotsize PM Owner's Name Tri/Valley Growers Address P.O. Box 3327 Modesto, CAPhone 572-5515 1 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Oi OTHER J� Monitoring We l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 100 , DISPOSAL FLO. N/A PROP. LINE N/A FOUNDATION _3 r AGRICULTURE WELL _2J)D 1 OTHER WELL_ N 4 A PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private R Gravel Pack CJ Tracy Type of Casing Sa' + i rhari Specifications ` ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 11 Type of Grout 1 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed1by k#k Repair Work Done ❑ Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 50'1 h Monitoring Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW �IN LLATION ❑ REPAIR/ADDITION 11 DESTRUCTION ❑ (No septic system permitted if public sewer is/ available within 200 feet.) Installation will serve: Residence mercial_ Other t Number of living units: Number of "ms Character of soil to a depth of 3 feet: \` / Water table depth SEPTIC TANK ❑ Type/Mfg dapacity L1 No. Compartments PKG. TREATMENT PLT. ❑ /1. Method of Disposal Distance to nearest: Well �� - Foundation Property Line ` LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED ❑ Distance to nearest: Wella Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ► DISPOSAL PONOS C] / I 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.�Califomia."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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. 4 Signed ti � Title: Date: Z 4a I� P NT USE ONLY I Application Accepted by Date S-/_'�� Area A Pit or Grout Inspe ' by Date Final Inspecti,by Date I� Additional Comments: G Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑ Tracy 8358M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i' � w INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. EH 13-28 �"S fc]p �( � �`3� ��I