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APPLICATIOIN FOR PERMIT <br /> SAN JOAQUfN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA j <br /> Telephone (209) 466-6781 L ' <br /> PERMIT EXPIRES '!'YEAR FROM DATE ISSUED i <br /> (Complete in Triplicate) U 1Q <br /> J" <br /> Application is hereby made to the San Joaquin Local Health district for a permit to construct and/or instal! <br /> made in compliance with San Joaquin County Ordinance Nothe work herein described. This application is <br /> . 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 526 N. Broadway Stockton <br /> City Lot Size PM <br /> Owner's Name Glen Adam NaaszAddress 526 N. Broadway <br /> Phone 464-3388 <br /> j <br /> Contractor Williams Plumbing _Address 2360 N. Wilson Way 2g <br />' TYPE OF WELL/PUMP: License No. 9293 Phone 466-4004 <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER 11SEWER LINES DISPOSAL71FLD" — PROP`LINE—:! <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private C Gravel PackDia. of Well Casing <br /> 0 Tracy Type of Casing <br /> 1-1 Public i_1 Other n Delta Specifications <br /> Depth of Grout Seal_ Type of Grout <br /> I i Irrigation --Approx. Depth I I Eastern Surface Seal Installed by 1 <br /> Repair Work Done' ❑ Type of Pump H.P. ` <br /> Well Destruction ❑ Well Diameter State Work Done <br /> Sealing Material (top 50') # <br /> Depth Filler Material (Below 50') W } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION {No septic system permitted if Public sewer is <br /> Installation will serve: Residence_ Commercial— Other yy,. vailable within 200 feet.) <br /> i ". �. <br /> Number of living units: Number of bedrooms <br /> Character.of soil to a depth of 3 feet: <br /> !` SEPTIC TANK _ z Water table depth <br /> ❑ Type/Mfg Capacity + No. Compartments <br /> PKG. TREATMENT PLT, L] 1 <br /> F Method of Disposal �[ <br /> Distance to nearest: Well rt _ �,. <br /> Foundaiidn Property Line <br /> YA � • � <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED Total length/size t <br /> ❑ Distance to clearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS i I Depth Size <br /> SUMPS Number' <br /> L� Distance to nearest: Well Foundation <br /> DISPOSAL PONDS � ❑ Property Line <br /> I hereby certify that I have prepared thisapplicationand that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: ••I certify that in the performance of the work for which this <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or s b -contract ngrmit.is issued, ls shanot <br /> gnaturre <br /> 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- <br /> tion laws of California." <br /> The.applicant mu I for ail r fired inspectionsd Complete drawing on rse side. r <br /> Signed X Title: J <br /> —� /L ---Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by } � <br /> Date . rea � <br /> Pit or Grout Inspection by Date <br /> by �••� Date /! <br /> Additional Comments: /V,:? <br /> Final Inspection <br /> ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIVNO. <br /> ( �. <br /> + EH 13-24(REV.iiRss e <br />