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APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA y Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, ANNE1)__c (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 Address 18846 N Hwy 99 City T,odi LotSizei7() PM Owner's Name ViCtOr Fine Foods Address same Phone464- 64 1 393 Contractor Clark Well Address 202g E. r]3astnr License No. 371560 _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTIOX)i2C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 2 ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications 1�e t7 Public fl Other D Delta Depth of Grout Seal Type of Grout U a 'I i Irrigation --Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ 1 Well Destruction ;R^'Weil Diameter 1 611 Sealing Material (top 501 6 sack sand t� Depth 34R Filler Material (Below 501 same TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) N Installation will serve: Residence_ Commercial____ Other S Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth p SEPTIC TANK ❑ T � Type/Mfg ype g Ca pacify No. Compartments PKG- TREATMENT PLT. ❑ Method of Disposal 4 Distance to nearest: Well Foundation Property Line �r LEACHING LINE ❑ No. & Length of lines Total length/size 5 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line T_ 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, anM-_, rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: '1 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." Contractors 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 C ifo i vi The applica II o all r ire s ctions, Complete drawing on reverse side. {} Signed X Title: VP t'l a rWel] Date: 33 May 9�n '� FO EPARTMENT USE ONLY /A� (• „ Application Accepted by Date lJ Area Pit or Grout Inspection by Date Final Ins action by Q?, 2"t Date n� Additional Comments: ' O ( � ❑ Stk 466,6781 ❑ Lodi 369-3621 TO Manteca 823-7104 CfTrac 5 Applicant - Return all copies to: r ental He h Permit/ rvices 1 1 E. Iton Ave, P.O. Box 2009 Stk., 95201 `t oma" 3S0 CK A INFO A OUNT DUE AFEE MOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH1 -21(REv.lin5) 15(��/EH 114-2t1