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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12W 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> made in compflance with San Joaquin Ccrunty Ordinance No.649 for sewage at No.1862 for wall/pump and the Rules and Regulations of the San Jwuin <br /> Local Health District. . I . . Assessor #177-100-22 <br /> 2467 E . French Camp-- Rd French Camp 4251-3231 � Parcel C— <br /> Job Address city A Lot Size— PM <br /> . ace Tomato Co. 2771 E. French .Camp Rd 98275691 <br /> Owinir's Name Address Phone <br /> Contractor'sNams Clark Well License No. 371560 Phone 462-7676 <br /> TYPE OF WELL/PUMP: NEW WELL 6 WELL REPLACEMENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION, SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCETO NEAREST: SEPTIC TANK 10 SEWER LINES —.DISPOSAL FLO. 150 PROP. LINE 15' <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL— PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> X) Industrial Open Bottom 0 Manteca Die. of Well Excavation 2F11 Die. of Well Casing -161, 4 <br /> 1771 Domestic/Private Gravel Pack 0 Tracy TypeofCatting '31'0131 spait�ificatlons .250 <br /> 0 Public 0 Other Ei Delta Depth of Grout Seal 5 fl TypacfGrout (9 sack), <br /> El Irrigation _-Approx DeFr 0 Eastern 1 afffaca Seal Installed by 0�tr <br /> Repair Work Done 0 Type of Pump urbine H.P. state W�Dom install <br /> Well Destruction Well Diameter Sealing Material (top W) <br /> Depth Filler Material(Below 5D') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION LI DESTRUCTION 0 (No septic system permitted if public sewer.Is <br /> avallable within 200 feet.) <br /> Insuillation wil serve: Residence— Commercial— Other it <br /> Number of riving units: — Number of bedrooms C <br /> Character of s6l to a depth of 3 feat; —Water table depth <br /> SEPTIC TANK EI Type/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE El No. &Length of lines Total length/W <br /> FILTER RED EI Distance to nearest: Well Foundation Property Line <br /> ,SEEPAGE PITS 0 Depth —Size Number <br /> SUMPS 0 Distance to nearest: Well— Foundation Property Line <br /> DISPOSAL PONDS 13 <br /> I herabycenify that I have prepared this application and that the work will be done in accordance with Son Joaquin county ordinances, state laws, and <br /> rules and regulations of the Son Joaquin Local Health District. <br /> Home owner or lic.smad agerit'6 siamure certifies t a owing: "I certify that in the performance of the wcrk for which this permit is issued, I"it not <br /> employ any, son in cjFF;;rm9rss t barcome subject to wtirkman's compensation laws;of California." Contractor's hiring or sub-contracting signature <br /> owing that I —nce of <br /> cenrl'i the=OH that I mionce of the wt,rk for which this permit Is Issued, I shall employ persons subject to workman's compense <br /> `h�f ii�lfo k <br /> tion Laws of ifo ia." NA4) <br /> The applics f red i plate drawing on reverse side. <br /> s,grmd 1:0el Title: VP-Clark Well Date: 4 Oct 1985 <br /> FOR DEPARTMENT USE ONLY <br /> Appficstl� red by Date L) 97� <br /> f <br /> Pit o on by O�6 0-*­W'� Final Inspection by at, <br /> cGrlut'1)p,,ti <br /> Addidonal Comments: <br /> 0 S* 466-Ml 0 Lodi X9-3621 0 Merriam 823-7104 C3 Tracy 83!5�6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Servicas 1801 E. Hwekon Ave., P.O. Box 2009, Stlk., CA 95MI <br /> FEE I AMOUNT DUE AMOUNT REmirrED RECE <br /> I INFO L_._ <br /> ,as-%- <br /> M 13-N(REV.10183 <br /> EN IA�lr I <br />