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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District.- Alleyway ,fob Address Between N. [nTalnutiand N. Stockton City Ripon Lot Size PM I' City of Ripon) 312 W. 4th Street (209) 599-2108 Owner's Name Address Phone 16018 Valley Blvd. Contractor Layne Environmental Address Fontana, CA 92335 License No. 452609 Phone 714 3557335 TYPE OF WELL/PUMP: NEW WELL,_ -10A _ F1 -RJ[ PLACEMENT U DESTRUCTION 171° PUMP INSTALLATION [D" lJ SYSTEM_ REPAIR ❑ OTHER ❑ DISTANCE 70 NEAREST: SEPTIC TANK NA SEWER LINES, 75 0 DISPOSAL FLD. NA ' PROP. LINE NA FOUNDATION 401 AGRICULTURE WELL NA OTHER WELL NA PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS See Attached Table ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 znc Dia. of Well Casing 4 inch ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications M Public f OtherMonitorinig Delta Depth of Grout Seal Type of Grout Volclay/C.ement I i Irrigation + __-Approx. Depth I I Eastern Surface Seal Installed by Layne Environmental Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I INo 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' EI Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 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 1 Depth Size A Number SUMPS 'i' Ll 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 taws, 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,I shall employ persons subject to workman's compensa- tion laws of California." f The applicant must cal or,all re wired inspections. Complete drawing on reverse side. ( {� Plant Manager z U V Signed X Title: Date: FOR DE RTM NT USE ONLY ` Application Accepted by Date Pit or Grout Inspection by Date Final Inspection Dates`" Additional Comments: ❑ Stk 466-6781 EI 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 INFO AMOUNT DUE AMOUNT REMITTEDL!KRECEIVED BY DATE PERMI7'NO. EH t3-241REV.I/a5) EH 142a - 1 Applicant is Nestle Foods, owner is City of" Ripon. Agreement is attached.