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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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. 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. Job Addres 18846. N. 88446N. Hwy 99 �` City Lodi Lot Size PM Owner's Name Victor Fine Foods Address same Phone 464 1393 Clark Well 2024 East Charter Wg�/ 371560 462-7676 Contractor Address LrCense No. Phorie TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION EX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK __+1 S_d SEWER LINES DISPOSAL FLD. PROP- LINE ?moi r FOUNDATION AGRICULTURE WELL OTHER WELL 100 r PITS/SUMPS INTENDED USE TY-PE-0.F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private LI'Gravel Pack ❑ Tracy Type of Casing _ Specifications 1"1 Public n Other Cl Delta Depth of Grout Seat Type of Grout ¢ I I Irrigation T Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Turbine H.P. 50 State Work Done install Well Destruction ❑ Well Diameter Sealing Material stop 501 l� Depth Filler Material (Below 501 _T V- TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I 1 (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 length/size-- FILTER ength/size _FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C- I 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 Di.,trict. 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 the performance of work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of Cal' rni . The applica s all a u- d i ro C plate drawing on reverse side. Signed Title: VP Clark We l,1 Date: 16 Marc-h 1 9 8 9 FORDEPARTIMENT USE ONLY r Application Accepted by O � v.�-� Date ^��"^ Area Pit or Grout Inspection by _ Dato Final Inspection by_ _ Date o-W Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835385 / Applicant - Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFOCK i FEE OUNT DUE �A�MO(U�/NTT REMITTED CASH /�/REECEIVED BY DATE PERMIT'NO. f.EH 13-24(F1 EV,t i n 5i ��'}� {.J� �S[�" , 3-� � 1 u U—/ EH 14-28 v