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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.<HAZEL T ON 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.TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for we / ump and the ule��and R iol�r�q#the San Joaquin Local Health District.. �r, gS6sSQr I 77—Tut + 2467 E. French Camp fid French Camr , ° 425--323 Parcel C--2 Job Address City of Size PM Owner's Name Ace Tomato Co•.. Address 2771 E; French Camp Rd Phone 982-5691 Contractor's NameClark 'well License No. 371560 Phone 462-7676 TYPE OF WELL/PUMP: NEIN WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK 150'.. SEWER LINES DISPOSAL FLD. 1 50 f PROP. LINE 15 t FOUNDATION AGRICULTURE WELL OTHER WELL 50 r PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation tl Dia. of Well Casing tt 61 Domestic/Private JC Gravel Pack ❑ Tracy Type of Casing Steel Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 9 SaCk ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Clark Repair Work Done ❑ Type of Pump S I I h H.P. 1 1.12 State Work Done install Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth '' Filler Material (Below 501" J TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION 11DESTRUCTION 11 (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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthisize FILTER BED ❑ Distance to nearest: Well Foundation Property Line i { SEEPAGE PITS ❑ 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 1; certifies the following:"I cert in performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applica cal 'r r q ins pl drawing on reverse side. SignedTitle: UP—Clark Uell Date: 4 ftt'r 1985 c. FOR DEPARTMENT USE ONLY Application Accepted-by M Date O I V Area Pit(ginspection by Final Inspection by Date, I b -a Additional Comments: t �b- ❑ Stk 466-6781 ❑ Lodi 369-3521 C] Manteca 82_3_--17& ❑ Tracy 6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.;CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. F rss + EH 13-241REV-10/831 1fl G r