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r - t 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) Applicaon is /or install the work n describe .This cation is made inti compliae,ebynce wwith Sano ade toJoaquin County ordinathe San Joaquin Localncle No.549 for sewage or ealth District for a permit No. 1862 for cwell/dpump and the Runes and IR gulations of he San'Joaquin Local Health District. Job Address 230 Industrial Ave. City R100n Lot Size PM Nestle Foods Corp. Address 230 Industrial Ave. Phone (209)599-4161 Owner's Name P License No. Phone 415 495-50 9 Contractor Address Dresser & McKee Address100 Sear St. ,Ste. 700 ) TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER §lonitoring Wells DISTANCE TO NEAREST: SEPTIC TANK > 100 SEWER LINES > 751 DISPOSAL FLDNone PROP. LINE Variable FOUNDATION Variable AGRICULTURE WELL 1001 OTHER WELL 751 PITS/SUMPS »> o INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr 01 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9/t r r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing pVC Specifications Delta Depth of Grout Seal lTa ri ahl a Type of Grout VO1ClaV Fl Public lA Other Monitor in@ Cont rartnr - I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump None H.P. State Work Done — 411 Sealing Material Itop 50'1 Volclay Well Destruction ❑ Well Diameter 0 Depth Variable Filler Material (Below 501 Sand stem TYP OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I availablelw thin 200 t et.) if public sewer is Installation wi esidence_ Commercial_ Other Number of living units: _ 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 Distance to nearest: Well Foundation Property Line 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 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 17 1 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. "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: ' 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' certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of Calico The applica call for all qui s ons. Complete drawing on reverse side. Signed X Title: Hydrogeologist Date: 10/15/87 FOR DEPARTMENT USE ONLY Application Accepted by Date U -/ �,L c�1T� Date Final Inspection by Date Pit or Grout Inspection by(11 /Q!/! )17 Additional Comments: 4,i� / e , ❑ Stk 466-6781 11 Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies tp. Environmental Health Permit/Service E. Hazelton ve., P.O. Box 2DO9, Stk., CA 95201 FEE AMOUNT D AMOUNT REMITTED CASH RECEIVED BV DATE PERMIT NO. INFO _ O �� ^ 'Oy ♦ EM 13.24 IREV.1/x5) EH 1426 V✓