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APPLICATION FOR PERMIT .Hughes Const. SAN JOAQUINLOCAL HEALTH DISTRICT State Lic. #267177 1601 E..HAZELT.ON AVE., STOCKTON CA 263 S. Oro Ave.. � I tockton, i A 9 20 Telephone 12091 466-6781 PERMIT EXPIRES 7 YEAR-FROM DATE ISSUED :S Phone: (209) 944-9937 'rt`a?Lr G belwc� i,t , . ;� .,.;<,.,(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 welt/pump and the Rules and Regulations of the San Joaquin Local health District.e•xe3&r1i'£rf€ '• ' 7 t0 Job Address [!! Y: �• City Lot Size PM -�J✓�L - Owner's Name � _ _ Address . _. Phone Con .or s-Nartme"" License No ' �-Z_7. -- - ------- - - Phone.-Ogg—P, ` TYPE OF-.WELL/PUMP: NEW ELL_❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ T PUMP INSTALLATION ❑T. x r SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO"NEAREST: SEPTIC TANK SEWER LINES-^— - ''DISPOSAL-FLD. PROP. LINE .0, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � t INTENDED',USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ IMustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ 'Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ♦. ❑ Tracy Type of Casing kSpecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout. ❑ I Ligation Approx. Depth .❑ Eastern Surface Seal Installed by # Repair Work Done : ❑ Type of Pump H.P. State Work Done We11�Desiructton ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 7.DESTRUCTION ❑ (No.septic system permitted if public sewer is _ r available within 200 feat) Installation will serve: Residence A- Commercial Other k Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r" SEP71C TANK- .--m *'❑ Type/Mfg'�(� t7-327/wer Capacity No. Compartments PKG. TREATMENT PL#T.. 11 Method Method of Disposal Distance to nearest: Well Foundation Property Line`' LEACHING LINE No. & Length of lines -~ Total length/size r f FILTER BED 'Distance to nearest; 'Well, dr Foundation' � Property Line $ SEEPAGE PITS IX .Depth ___. :S_ -Size Number s h SUMPS ❑ 'Distance to nearest: Well Foundation !D Property Line' _.....3S— `DISPOSAL PONDS_F 1 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 foltowing: "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- tiont laws`of California."s-- The applicant must call for all required inspections. 9omplete drawing on reverse side. > Signed w Title: Date: �Ja � -FOWDEPARTMENT USE ONLY-- r lication Accepted by Date Area . . ..me :. . ...�e. Brae-- Pit r_Grout Inspa�tion by `�` Final Inspection by Date A- ag`A�s t Additional Comments +~ ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant:- Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 35201 'FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 6Y DATE PERMIT-NO. INFOii +EH i124 TREY.101831 #.. �.. EH 1 •#•. �. . '^-!�� - ^`- '�- 7� 74Z8 i 3