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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 10195 DATIS RD City STOCKTORT Lot Size 1'l ac PM Owner's Name LdlNIR 13' I Address SAIM Phone Contractor KEITH GROSS Address 20' BRY. -4 73 License No. 537385 Phone 33,4-47215 TYPE OF WELL/PUMP: I� NEW WELL Q WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ + DISTANCE TO NEAREST: SEPTIC TANK 1.20 •i- SEWER LINES DISPOSAL FLD. PROP. LINE 10 i - FOUNDATION AGRICULTURE WELL OTHERtWELL—'40 \ PITSISUMPS INTENDED.USE. TYPE OF WELL _PROBLEM AREA CONSTRUCTION SPECIFICATIONS f, ❑ Industrial Q Open Bottom _❑ Manteca' Dia. of Well Excavation 'I 111 _r Dia. of WellCasing F [Domestic/Private Gravel Pack t❑ Tracy ► Type of Lasing Specifications JCJF'1 Public F] Other n Delta Depths of Grout Seal I P—O- Type of Grout I 1 Irrigation �_.Approx. Depth l I Eastern Surface Seal Installed by C'071'.- aj:r nr X _ Repair Work Done ❑ Typeyof Pump � H.P. 13 `r State Work Done _WANT ,STII ,JaC Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Fillet Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [.1 REPAIR/ADDITION LI DESTRUCTION f I (No septic system permitted if public sewer is ~ available within 200 feet.) -4) Installation will serve: Residence_ Commercial— Other Number of living units: IM Number of bedrooms r (A Character of soil to a depth`oiF 3 feet:— y Water table depth 1 , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Il {fv ..a .- Method of Disposal f xDistance to nearest-. Well k Foundation Property Line LEACHING LINE ❑ No. & Length of lines ! Total length/size C FILTER BED T ❑ Distance to nearest: Well Foundation Property Line �/1 SEEPAGE PITS F I Depth Size 9 Number _ SUMPS 0 Distance t r barest: -Well 3 ' foundation Property Line DISPOSAL PONDS ❑ Il 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 rules and regulations of the San.[Joaquin 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." Contractor's 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." - v v The applicant must Ycall lffor all required inspections. Complete drawing on reverse side. Signed X � � ! Title: OWIT'R 8 � ..._ Date: S-�2�--0) II FOR DEPARTMENT USE ONLY Q�� N Application Accepted by i Date C� Area li i Pit or Grout inspection by I Date Final Inspection by Additional Comments: I� ❑ Stk 466-6781 ❑ Lodi ili369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: E nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CARECEIVED BY DATE PERMIT NO. +.EH 13-24(REV.1 i 9 51 O� `' ySH s� ( �Lt_r' z Z EH 14-2e it p IN