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t ; �4 - : APPLICATION FOR PERMIT ; SAN JOAQUIN LOCAL HEALTH DISTRICT T .. s: 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 1045 West Charter Way CityStockton Lot Size PM Nomellini Construction ! Owner's Name Address 939 West Charter Way, Stockton Phone 209 466-50 2825 East Myrtle-Street Contractor Spectrum Address Stockton, CA 95205 License Nod-57-51226 Pho4209 948-134 t TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE:TO-NEAREST: SEPTIC TANK SEWER LINES 50' DISPOSAL FLD. PROP. LINE SSU% FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r�S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing 211 ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Schedule 40 PVC Specifications f"1 Public lyi Other RI Delta Depth of Grout Seal 15' Type of Groutcement bentoi ite I I Irrigation - 30 r_Approx. Depth I I Eastern Surface Seal Installed by SAectrum M - Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ WeE1 Diameter 21r Sealing Material Itop 50 cement bentonite .� Monitor Depth 30' Filler Material (Below 501 Q TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION LI DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence ;Commercial— Other Number of living units: Number of bedrooms I 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' t Distance to nearest: Well Foundation Property line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ " Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I 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 Oiltrict. 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 parsons subject to workman's compensa- tion laws of C r ia." The app mu t call for all required inspectio mplete drawing73ZADa Signed X Title: te: FOR DEPARTMENT U ONLY Application Accepted by Date re i Pit or Grout Inspection by Date Fin Ins tion by Date Additional Comments: Ali r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 104 ❑ Trac 635-6385 �, " Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BoStk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED R RECEIVED BY DATE PERMtT'NO. +.EH 13-24(REV.1/n s) ['b� '-'r—r7 C/ �y 65 EH 14-28 C9C 1 V O I