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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH 'DISTRICT 1601 E. HAZELTON 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. i Job Address 11 South "A" Street City S to,Cj€ton Lot Size PM I f Owner's Name Tri/valley Growers Address P.O. Box 3327 Modesto, CAphne 572-551Y Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 5d Monitoring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ; ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing See attached. specifications I i ❑ Public ® Other ❑ Delta Depth of Grout Seal 'I Type of Grout 03Irrigation 2-5—'Approx. Depth ❑ Eastern Surface Seal Installed by a h. Repair Work Done ❑ Type of Pump H.P. [State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') k Monitoring Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ o septic system permitted if public sewer is k i available within 200 feet.) t Installation will serve: Residence— Commercial Other r Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityIl No. Compartments PKG. TREATMENT PLT. © Method of Disposal Distance to nearest: Well ndation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 7 _ Foundati Property Line i I� SEEPAGE PITS ❑ Depth So Number SUMPS Cl Distance to nearest: ell Foundation ! Property Line DISPOSAL PONDS ❑ I� I l 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. I[ i 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 iss led,I shall employ persons subject to workman's compensa- tion laws of California." The applicant-rrAust call for all required in ions. Complete drawing an reverse side. is 4 Signed Tide: Date: }Z I �AE Ol11LY Application Accepted ate —/3— Area /Sr Pit or Grout I cti y Date Final Inspection by Date Additional Comments: Ir ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 8354635 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Aved, P.O. Box 2009, Stk., CA 95201 ` INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'Na. 3-24. + EHif'2aIRE1/.1/951 ��. G� I��S - �43/� -�'Za