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SAN JOAQUIN LOCAL HEALTH DISTRIC.P PAY&1ENT 1601 E. HAZEL T ON AVE., STOCKTON, CA R lEC EI V ED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �C T (Complete in Triplicate) INVJRO NME Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wok 4J6k.WCAt'1plication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ridesa San Joaquin Local Health District. Job Address 711 S. San Joaquin Street city Stockton Lot Size 80,000 FT 2 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 Explorat*99ess 2825 E. Myrtle, Stockt9-11,,,nse No. 512268 Phone (209) 405-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9112 Boreholes for DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LrSN'Eil Sampling FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom L7 Manteca Dia. of Well E..avation lnc Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 1_J Tracy Type of Casing Specifications f-1 Public f1 Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation 12-14 ETApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done 17 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material ftop 5011 Depth Filler Material !Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I d REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) 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 Ll No. $ Length of lines Total length/size FILTER BED L] Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 D3trict. 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." The applican ust call for all re u' ctions. Complete drawing on reverse side. Signed X Title: ��ILI'd✓ ea iG�X Date: /4 rF FOR DEPARTMENT USE ONLY J f p Application Accepted by G'�1-j <-,p'Date / 1 O p 0 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED INFO +� ASH RECEIVED BY DATE PERMIT'No. + EH 13.21 IREY.i i n sl ' EH 11-28 .J