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` PAYMENT APPLICATION FOR PERMIT ®� SAN JOAQUIN LOCAL HEALTH DISTRICT SAN 2 8 1988 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES TYEAR FROM DATE ISSUED PFRMITIS>="CES (Complete in Triplicate) ribe . This cation is Applicationl `lance with a to the San Joa 1 Joaquin County Ordinance No.549 for sewage o on Local Health District for a permit No. 1862 for wellldpump install nd the Rules and herein Regulations of he San r Joaquin made P Local Health District. l 1014 North Eldorado Street city Stockton Lot Size 150' x 150' PM Job Address Bud et Car Rental SalesAddress 1014 N. Eldorado St. , Stockton Phone (209)941-0434 Owner's Name 5729-F Sonoma Drive 480942 Phone (415) 462-40 0 - BSK & Associates Address Pleasanton, CA 94566 License No..�_�-- Contractor...�� .TYPE OF WELL/ MP: NEW WI=LL ❑ WELL REPLACEMENT LlDESTRUCTION ❑ PU PUMP INSTALLATION ❑ -,...SI'9TEM REPAIR ❑ OTHER C�( Soil Boring SEVtiIER-L"(NES'`""�" — DISPOSAL`FL`D r'"'""""'""PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK " _ FOUNDATION-1 AGRICULTURE WELL OTHER WELL YPlTS/'SUMPS --�— _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.- f Well Casing ❑ Industrial El Open Bottom, ❑ Manteca. bio_ of Well•excavation— Rl l ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ^Depth of Grout Seal 1 to 7flt — Type of Grout f-1 Public fXOthesOil BOrlrl�llDelta ti,� ) � �, I I Irrigation - 2W_ Approx. Depth i I Eastern Surface 54eHlnstalled by # ^J 24, •: (" -• p� State Work Done—_ Repair Work Done ❑ Type of Pump k rt Sealing Material (top 50'1 \ Well Destruction D Well Diameter 9 I i Filler Material (Below 501 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION l DESTRUCTION l I (No seavailabptic ih in system feertted if public sewer is I- -� . -. Installation will serve: Residence_ 'Commercial Other - ' Number of living uniis: Number of bedrooms _ Water table dep� ° Character of soil to a depth of 3 Vfeet: rn SEPTIC TANK ❑ Type/Mfg Capacity No.'Compartments : Method of Disposal PKG. TREATMENT PLT. ❑ I ,jt .` i i t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of:Uines'-( '. ', Total length size FILTER BED ❑ Distance to La�est: Well Foundation Property tine 3 SEEPAGE PITS I _ Depth,_ ._ _ _Size_ . ..._ .-. . _ .. _ Number'\ l SUMPS L� Distance to nearest: Well• F,•oundation. x i Property Line �n ;P DISPOSAL PONDS ❑ 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. i 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 or sub-contractnsignature employ any person m such manner as to become subject to workman' cs compensation laws of California." Cantracteo nsrsubring ect t workmanlscompensa- certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 tion laws of California." ' The applicant must call for all required inspections. Complete drawing on reverse side. 01125/88 1125188 Title: Manager - Engineering Date: l Signed X .X.C�( , FOR DEPARTMENT USE ONLY 2- f-.L Area Application Accepted by Date Data Final Inspection by Date Pit or Grout Inspection by x Additional Comments: ❑ Stk 466-6784 ❑ Lodi 369-3621 ❑ Manteca 823-7444 ❑ Tracy 835-6385 1601 E. Wazelton Ave., P.O. Box 2049, Stk., CA 95241 Applicant - Return all copies to: Environmental Health Permit/Services FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV,t/H 5r `J'� 4 EH 14-2e t`