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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (269) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM`DATE ISSUED <br /> (Complete in Triplicate) . application is <br /> construct <br /> Application is hereby made <br /> h San Joaquin heSCounty Ordinance Health <br /> District <br /> for sewage ofor a perr'Noo 1862 for wandl or install the Work heren described. Thi <br /> ell//pump and he Ryles and 1Regulations of he S n Joaquin <br /> made in compliance w �� <br /> Local Health District. } ,;s �)� kn <br /> �•,rl 4 City �TpC1C_ q I? Lot Size r PM <br />` Job Address <br /> Owner's Name EnLi. Croce <br /> i Address 3333 E.• urns@ Phone <br /> I 117707 E. Hwy 26 License No. 377��3 Phvne887�'3`�54 <br /> Contract WELL�f IIIIn$�� Address U( <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> L7DISTANCE <br /> F WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> SEWER LINES ��-- DISPOSAL FLD. PROP. LINE TO NEAREST: SEPTIC TANK ��— PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation <br /> ❑ Tracy Type of Casing specifications <br /> ❑ Domestic/Private C] Gravel Pack Depth of Grout Seal Type of Grout <br /> Ll Public ❑ Other (-y Delta <br /> �pprox• Depth ,❑ Eastern Surface Seal Installed by i nEta11P� nPUMP <br /> Irrigation <br /> ' Submersilp a 71h State Work Done --EW <br /> Repair Work Done ❑ Type of Pump _�— Sealing Material (top 50'1 PSP <br /> Well Destruction ❑ Well Diameter <br /> �'- <br /> Depth " - I Filler Material (Below 50'1 <br /> available within 200 feet.] <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION=d";REPAIR,ADDITIO (No septic system permitted if public sewer is <br /> N ❑ DESTRUCTION ❑ <br /> Installation will serve: Residence, Commercial Other <br /> s <br /> Number of living units: Number of bedrooms f` ►, , Water table depth <br /> Character of soil to a depth of 3 feet:__... __,. - t Capacity No. Compartments <br /> 1 SEPTIC-TANK i] Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well . <br /> i <br /> Total length/size <br /> LEACHING LINE ❑ �No. &Length of fines <br /> �. Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> i <br /> Size Number <br /> SEEPAGE PITS ❑ Depth' <br /> Foundation Property Line <br /> SUMPS ❑ Distance to nearest: ;Well <br /> DISPOSAL PONDS_ _u ❑ _. ., <br /> r' <br /> I 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 <br /> rules and regulations of the San Joaquin Local Health District. work for <br /> "I certify th.at in the performance of Home owner or lice. agent's Her as to become subject to following: <br /> workman's compensation laws of Californiafi�Contractors shiring or sub-contracting cornnatuae <br /> employ any-perso nsa <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's comps <br /> tion Ia n;a." late drawing on reverse side. <br /> The plicant m st all for all ire spections. Comp <br /> Signed Title: CC3r1]• SEC <br /> ry <br /> FOR DEPARTMENT USE ONLY <br /> i Date Ji/ Area Q... <br /> d b <br /> tApplication Accepey <br /> I <br /> I <br /> Final Inspection by <br /> Pit or Grout inspection b <br /> Date " <br /> F " <br /> Additional Comments: <br /> C] Stk 4&6-6781 ❑ Lod; 369-3621 El Manteca 823-7104 ❑ Tracy 1135 6385 <br /> P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., <br /> CK# RECEIVED By DATE PERMIT`N0. <br /> + FEE" AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> F a <br /> +EH13-24(REV.1/85) <br /> EH 14-28 <br />