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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 601 E. HAZE I ON AVE., STOGK70N, CA Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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. 4 r Job Address _. 1012 " . BROA.DVdAY City STOCKTON Lot Size PM Owner's Name V=ETTA MCGLADE Address 1012 S. BROADWAY Phone 463-1629 Contractor Address 1035 S_ Aurora St_ License No. 202228 Phan, 46 --1 06 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca "5 Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r ❑ Public ❑ Other /❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth (D Eastern SurfaceSeal-installed by Q Repair Work Done ❑ Type of Pump H.P. ; State Work Done ^Y Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (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 A No. Compartments PKG. TREATMENT PLT. ❑ �° Method of Disposal Distance to nearest: Well Foundation F Property Line i LEACHING LINE ❑ No. &,Length of lines j Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well'—' '-"'" ' ' 'Foundation Property Line DISPOSAL PONDS ❑ l I hereby certify that I have preparW,this application and that the work will be done in accordance with San Joaquin'county'ordinances, stair laws, and 1 rules and regulation 6.'of the San JaBquin 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."Contractors 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 applicapflqust call for all required inspections. omplete drawing on reverse side. f Signed Title: President Date: 12/15/87 FOR DEPARTMENT USE ONLY J Application Accepted by Date Z �/ jj ►►Area Pit or Grout Inspecti Date Final Inspection Gy r�. (a j, �� Date & Additional Comments: ` a 1_ L 1--f- 0 --[❑ 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 CK RECEIVED BY /DATE PERMIT''NO. J + EH 13-24(REV.i/e51 EH 1428