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• APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT PAY&IENT 1601 E. HAZELTON AVE., STOCKTON, CA R E C E►V ED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCT (Complete in Triplicate) .ENVIRON T Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wkk ME ilb��iq plication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules�Vgf the an Joaquin Local Health District. Job Address 711 S. San Joaquin Street City Stockton Lot Size 80,000 F1 PM Owner's Name FabriCare Address 711 S. San Joaquin Street Phone 209 405-5788 Robert E. Detrono — General Manager Stockton, CA (C-57) Contractor Spectrum ExploratU&ess 2825 E. Myrtle, Stockt:CLRense No. 512268 Phone (209) 405— 712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER KJ 12 Boreholes for DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. Ll. Sampling FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation lnc Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation 12-14_)•''TApprox, Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 _ Ul TYPE OF SEPTIC WORK: NEW INSTALLATION I 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 V ' 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 A LEACHING LINE ❑ No. & Length of lines Total length/size C FILTER BED ❑ Distance to nearest: Well Foundation Property Line 7S SEEPAGE PITS I I Depth Size Number SUMPS LI 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 n 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, 1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applica ff^^us't itcali for all to u' ctions. Complete drawing on reverse side. p Signed X {r. `r Title: t!:%!f Date: �aT E FOR DEPARTMENT USE ONLY Application Accepted by �.2/Lli�✓ Date ( � D O Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 023-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AM�OjUNT DUE AMOUNT REMITTED ASH RECEIVED BV DATE N/ PERMI7N0. .,EH 1a-241REV.1/x5) �/� // ¢yy EH 1428 / ZJ _U O