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Zw­ <br /> APPLICATION IfOR PERMIT <br /> Hughes const, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> State, U-1. #267177 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 2S" S. Oro Ave.. Telephone (209) 466-6781 <br /> stackion, CA 95205X <br /> Phone: (209) 944-90-337 PERMIT EXPIRES I YEAR.FROM DATE ISSUED <br /> Phone: <br /> in Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the vMrk her6in daicribed. This application is <br /> made in compfiance:With-San Joaquin County Ordinance No.599 for sewage or No..IM for well/pump,and the Rules and Regulations of the San Joaquin <br /> Local Health District— to <br /> C! <br /> Job Address 3 M <br /> Address <br /> Phone <br /> Owner's Name <br /> Conk ktor's-N,iiriii License No­,JC-,V <br /> TYPE-OF-WELL/PUMP- WFL!­ --1 rA -WELL REPLACEMENT D DESTRUCTION E <br /> PUMP INSTALLATION :3 SYSTEM REPAIR :3 OTHER 0 <br /> DISTANCE TOWEAREST: SEPTIC TANK SEWER LINES­7± DISPOSAL-FLD PROF. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— > PITS/SUMPS <br /> INTENDED',USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C 16dusuial L Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private 0 Gravel Pack 0 Tracy -type of Casing- Specifications <br /> LI Public; 0 Other El Delta Depth of Grout Sea] Type of Grout— <br /> • 0 Irrigation --�—�Approx. Depth .0 Eastern Surface Sea[ Installed by <br /> Repa0 1. <br /> ir Work Done Type of Pump H.P. State Work Done <br /> Well Destruction C1 Well Diameter Sealing Material(top 501 <br /> Depth Filer Material (Below 501 <br /> TYRE OF SEPTIC WORK: NEW INSTALLATION E! REPAIR/ADDITi 0NK 7.!)ESTR�91IPN :1 (No septic system permitted if public sewer is <br /> available within 200 feat.) <br /> lustallation will serve, ReskJence Ix Commercial Other <br /> Number of living un Number of bedrooms ir <br /> 7 \—Water table depth <br /> Character of soh to a depth of 3 feet; <br /> C�pacjtyo� ­— No. Compartments <br /> SEPTIC TANK- eType/Mfg.---- <br /> `1 Me thod of Disposal <br /> PKG. TREATMENT PLT.M <br /> Distance to nearest: Well Foundation Property Line!.— <br /> A. <br /> LEACHING LINE No. & Length of lin %es Total lengthisize-- <br /> FILTER BED El Distance to nearestWall, I TW Foundation'—ZYr . Property Line 6 <br /> SEEPAGE PITS Depth Sim Number <br /> SUMPS i 0 X <br /> 'Distance to nearest: Well Foundation AP Orop4rty Line'—s— <br /> DISPOSAL PONDS—Fj <br /> 7 <br /> I hereby certify that.I have prepared this applicaticin and that tl4ework will be done in accordance with San Joaquin county ordinances, state laws, and <br /> -rules and-regulations of the San Joaquin Loc'al Health DIstrlct. 4- <br /> 'Ho'e owner or lic&md agent's signature certifies the foltowih4� "I certify that in the peffo.rmance of the work for which this permit is issued, I shaN not <br /> rsubject�o workman's of California."Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become su 's compensation laws. <br /> certifies the following:"I cartirly that In the performance of the woA forWhich this pemvtisissued, I shall employpersons subject to workman's cornponsa- <br /> tion'laws,of Callfoinia 4 <br /> The;applicant must call for all required in ctions. omplate drawing on reverse side. <br /> Signed X Titlii: Date: <br /> --FOR DEPARTMENT USE ONLY <br /> f fly Area <br /> Accepted by Data <br /> lication Ac <br /> .Pit r Grout Inspection byFinal Inspection by Date 115 <br /> Acllit'ional Cornmerits: <br /> Ann <br /> K727 <br /> L:3 Stk Alffi-Mll ., L:,Lod 369-Ml 13 Manteca M-7104 ..0 Tracy 83&6385 <br /> Appicant--Return iffi.copies to: EnvironrneMi Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Stk., CA 2=1 <br /> • RECEIVED.EIVED 0.Y DATE. PERmrr*N0.�J <br /> FEE `AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> EH f3-24 tREV.16183) <br /> t 7 <br /> C) CD cr.0 1 1 <br /> EH 14-26 <br />