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' PAYMENT APPLICATION FOR PERMIT REF-IVE0 x� N SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA JAN l y 1�lj Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMITISERVICES 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 welilpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2115 West Washington Street City Stockton Lot Size PM 333 Market Street, Suite 1000 Owners Name Pacific Molasses Com an Address San Francisco CA, 94105 Phone 415 546-6011 2825 East Myrtle Street (209) Contractor Spectrum Address Stockton, CA 95205 License No.C57--51226 Phone_ '`948-1345 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER & Soil Borings DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ---- f ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing ---- Specifications 17 Public f 1 Other f-1 Delta Depth of Grout Seal 10, Type of Grout 'Cement, _ I } Irrigation Approx. Depth I I Eastern Surface Seal Installed by Spectrum �urry Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Cement Slurry i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION l I (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 4 Character of soil to a depth of 3 feet. Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line i z SEEPAGE PITS I I Depth Size Number SUMPS L1 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 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: "1 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of Cali The applica mu call or all r qui d ' s io s. Complete drawing on r rse si Signed X Title: Date: /12_12 ✓ FOR DEPARTMENT L1 ONLY Application Accepted by Date Are Pit or Grout Inspection by Date Final Inspection 7z zes ' 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 INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY PATE PERMIT NO. +.EH 13-24(REV. 11e1 EH 14-26 �d'SO �� S1 1751 . 1