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Y �4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 ` PERMIT EXPIRES TYEAR 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 weVpump and the Rules and Regulations of the San Joaquin Local Health District. 9111 942 S. Stockton Avenue Ripon Job Address City Lot Size PM �N 1 Owner's Name Simpson Paper Company P.O. Box 757, Ripon Phone 66T9s a ey v Contractor Layne Environmental Address Fontana, CA 92335 License No.452609 Phone(714)355-335 TYPE OF WELL/PUMP: it NEW WE4� w "- WEE l PLACEMENT L] DESTRUCTION ❑ PUMP INSTALLATION IJ- " " ESTE OUPAIR ❑ OAER ❑ 75' DISTANCE TO NEAREST: SEPTIC TANK NSA SEWER I-INES �� DISPOSAL FLD. PROP. LINE FOUNDATION N A AGRICULTURE WELL N/A OTHER WELL " PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS See Attached Table ElIndustrial ❑ Open Bottom 1:1 Manteca Dia. of WellExcavation 111C Dia. of Well Casing 4 inch ❑ Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing PVC SpecificationsVolclay/Cemen F] Public 'Xl OtherMOnitOriTl91 pelta Depth of Grout Seal Type of Grout •I t Irrigation —LApprox. Depth I I Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f:I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) S Installation will serve: Residence_ Commercial_ Other {! Number of living units: Ip Number of bedrooms n Character of soil to a deptlil of 3 feet: Water table depth f j SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line Q LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ 'i Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that 1 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. r Homeowner 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 1 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." III t The applicant must call f r all required inspections. Complete drawing on reverse side. i{ Plant Manager jZ r Signed X A Title: Date: I: FOR E TMENT USE ONLY Application Accepted by ' Date ea �S i Pit or Grout Inspection by��'�� bate Final Inspection by at Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appticant - Return all copies'rto- Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -I� FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24(REV.I/n 5) If 1i EH 14-28 f ent is attached. 1 Applicant is Nestle Foods, owner is Simpson Paper. Agreem