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APPLICATION FOR PERMIT .- SAN JOAQUIN LOCAL HEALTH Dl, AICT 1601 E. HAZELTON AVE. , STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( 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 pryStockton Lot Size PM go Owner's Name Nomellini Construction Address 939 West Charter Way , Stockton phone 209 466- 500 2825 East Myrtle Street Contractor Spectrum Address Stockton , CA 95205 License W97S —51226 Phond209 948- 134 TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 Monitoring Wel s - - - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1414- 1 , MW-2 , MW-3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 50 ' DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2u ❑ Industrial ❑ Open Bottom [3 Manteca Dia. of Well Excavation - - Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Schedule 40 PVC Specifications 11 Public W Other RI Delta Depth of Grout Seal 151 Type of Groutcement bentoi ii I I Irrigation WApprox. Depth I 1 Eastern Surface Seal Installed by Spectrum _ Repair Work Done ❑ Type of Pump H. P. _ State Work Done _ Well Destruction ❑ Well Diameter 211 Sealing Material (top 501 cement bentonite Monitor Depth 30 ' Filler Material (Below 609 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR / ADDITION t I DESTRUCTION I 1 ( 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 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 ❑ No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS - Ll 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 District. 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: '9 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 'f r ia." The applic mu t call for all required inspecti�s. Omplete drawing on rev rsq sid Signed Title: Date: FOR DEPARTMENT US ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: O Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 . ❑ Tracy 8356385 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 - CASN RECEIVED BY DATE PERMITNO, INFO ♦. EH 11-24 (REV. 1 EH 14-M