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r' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telepharie (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2S'q_ 32,-26 .97- (Complete in Triplicate) E., Jq/' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or i tat1.-the wo"Of �rein des d s application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump*416 Rules ands! III ti", a San Joaquin Local Health District. Intersection of 4th & Stockton Avenue '�O" (County Assessor Parcel 259-320-26) Ripon Lot Size Job Address City _ PM ',)- Owner's Name Robert White 1 Address 23363 Cypress Drive, Ripon Phone P.O. Box 50367 (415) Contractor Pitcher Drilling Address Palo Alto, CA 94303 License No. 263085 Phone_328-8910 TYPE OF WELL/PUMP: NEW WELL IN M-8DWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK >50' SEWER LINES y 50 t DISPOSAL FLO. NA PROP. LINE?50 r FOUNDATION 7 50 r AGRICULTURE WELL 750 r OTHER WELL NA PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Inc Dia. of Well Casing 5 inch ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications 't M Public (X Other Monitoring Delta Depth of Grout Seal 150' Type of Grout Cq.ment Ben_ I I Irrigation 180,1Approx. Depth 1 I Eastern Surface Seal Installed by Pitcher r Repair Work Done ❑ Type of Pump H.P. State Work Done_ N Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 h TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal (3-I Distance to nearest: Well Foundation Property Line . S 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 ❑ 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant musts call for all required inspections.'Complete drawing on reverse side. Signed X Title: Plant Manager Date: _1z-2,S gam~ D ENT USE ONLY ^� Application Accepted by Date Area t� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE )NFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 iREV.1/n 51a EH 14-Z6 �G 1 Applicant is Nestle Foods, owner is Mr. White. Agreement is attached.