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- �'Nor ' �. ��. �t "w• : APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �'• :` — 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (2091466-6781 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 insrall the work-herein described.This application b made in compliance with San Joauuin County Ordinance No.549 for sewage or No,1662 for well/pump and the Rules and Regulations Of the San Joaquin Local Health District. Job Address 1045 West Charter W:tv City Stncktan Lot Sire PM Ownet'sName \omellini Cons CCion Address932I t C rPr Wny- Srnrkrnn Phone(209) k66-5O.M Spectrum Addle tont �1 rt tee[ License No�-57-51226 Phone 209 94 134 Contractor P (_ ) 8 TYPE OF LVELLIPUMP: NEW WELL ` WELL REPLACEMENT ❑ DESTRUCTION ❑ .anitoring e PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER C MW-1. 1,11d-2. MW-3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 50' DISPOSAL FLD. PROP.LINE „— FOUNDATION AGRICULTURE WELL OTHER WELL. PITSISUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial U Open Bottom ❑Manteca Dia.of WrG Excavation pia.of Well Casing rt ❑DomesticlPrivate 0 Gravel Pack 0 Tracy Type of CasmgSChedule 40 PVC Specifications ['3 Public IX Other 1.Y Delta Depth of Grout Seal 15' Type of Groutcement ben tot it I I litigation 3..Q'Approx. Depth I i Eastern Surface Seal Installed by_ Spectrum _ Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter 2" Scaling Material Imp 50'1 cement bentonite rlonitor Depth 30' Filler Material(Below SO') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No seplic system permi:ted if public sower 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 0 TypelM!g Capacity No.Compartments PKG, TREATMENT PLT.Cl Method of Disposal Distance to neatest: Well_ Foundation Property Line LEACHING LINE ❑ No.8 Length of lines _ Total length/size— FILTER BED LI Distance to nearest Well _ Fnundation Property Line _ SEEPAGE PITS 11 Depth _Size---.—_ Number---_ SUMPS Ll Distance to nearest: Weir_ _ Foundation Property Line DISPOSAL PONDS 17 I hereby certify that I have prepared this application and that tire work will Let done in accordance with San Joaquin county ordinances,stats laws,and rules and ragulations of the San Joaquin Local Health 0,'51frct. Home owner or licensed agent's signature certifies the foliowrng:"I cattily that in the performance of the work for which this permit is issued,I shall nor employ any person in such manner as to became subject to wnrkman's compensation laws of California."Contractor's hiring Or sub-contraning signature certifies the following-"1 certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa• r tion laws o=ca ia," The appricacall for all requited inspect CompIola drawing on reverse side Signed x .1 /• G" Title: '•rte =E r Data: J "';t' FOR DEPARTMENT US ONLY 11 89 Application Accepted l,y _��..v~ Data Area Pit or Grout Inspection by _ Date Final Inspection by Data Additional Comments 0 Stk 466.6781 0 Lodi 369.3621 C h1amued 823.7104 O Tracy 835-085 Applicant- Return all copies to:Environmental fleahh Permit/Services 1601 E.Harolton Ave., P.O. Box 2009,S?k.,CA 95201 FEE INFO AMOUNT DUE AMOUNT RTED EMITASH RECEIVED BY DATE PERMIT'N0. EH u.�eI . za f�.t�•�. 7I1'<t '•�� -1 rte:.