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D.A. PARRISH & SONS, INC. CONTRACTORS LICENSE #10051 1 WWW.PARRISHANDSONS.COM P.O. BOX 8580 PHONE 209-466-9607 STOCKTON, CA. 95208 FAX 209-465-5736 APPLICATION FOR PERMIT w`" K s.r f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 andlor install the work herein described. This applicalbn is made in compliance with San Joaquin County Orchriance No Fr19 for sewage or No. 1862 tot well;pump and the Rules and Regulations of t+ie Sen Joarluin Local Health District. Job Address �,S�O � /Sr � City _S ___ -. Lot Size PM Owner's Name /.9J /lC S Address �AA9E -. Phone y P/ /�. A / �.,6 Coniracte> l.L< `:. C/+odress Q irr Yd� _ MOO tcense No.t �O*A _.Phone TYPE OF WELLlPUMP NEW WELL U WELL REPLACEMENT I DESTRUCTION J ` PUMP INSTALLATION I' SYSTEM REPAIR i7 OTHER 1 } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID.__. P, LINE __ AGRtCULTURE WELL OTHER WEL —_ PITS?SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION CATIONS i Industrial L Open Bottom it Mininwa Dia. xcavation Dia. of Well Casing r I Domestic/Private Cl Gravel Pack .-I Tracy Type of Casing —_-. SpeCItICetn)n5 + 1 1 I'I Public P Other _ _ -Olta Depth of Grout Seal Type of Grout I I Ifrigdhon __.- --Approt, Depth i I E75tem Surface Seal Insteliud by -- Repair Work Dane l Type of Pump H.P.__— State Work Done— Well Destruction U Well Diameter Seating Material ltop 501 1 Depth Filter Material(Below 501 r TYPE OF SWIC WORK: NEW INSTALLATION I REPAIRiADDITION I I DESTRUCTION I 1 (No septic System permitted If public sewn is j available:within 200 luet.l installation will serve: Residence_ Commercial X Other O Number of living units Number of lwdrooms , Character of soil to a depth of 3 feet: Water Iahte depth SEPTIC TANK LN TypelMfg 1�1 �..CfEcri Cauac,ty �O® -No. Compartments 00PKG. TREATMENT PLT.U Mellwd of Disposal C Distance to nearest: vMelT; Foundation Property Line t 4' LEACHING UNE L� No. 8 length of lines firs TpM 1NIallJflto y N i 4 FILTER BED O Distance to nearest: Well Foundation . T_ Prapally Line SEEPAGE PITS 04 Depth _._.Sire __T2 4 Number. Y CFO. SUMPS U Ostance to neatest Well fouedation Property Line DISPOSAL PONOS Cl J hereby certify that I have prepared this application and that rhe work will be done in accordance with San Joaquin county ordinances,state laws and rules and regulatipns 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 subcontracting signature candies the following. "I certify that in the performance of the work for which this pumat is issued,1 shall employ persons subject to workman's compen54- tion laws of California." Tfia applicant must call for all u�inspa�ons. mplete drawing on raver a side Sign tom' Title: OGd. .Q----_-- -- Date_ OR DEPARTMENT USE ONLY / Application Accepted bV Date 3 Area Pit or Grout Inspection byA, DateQ�I� t rFinal Inspection by Dale Additional Comments: U Slit 466-6781 D Lodi 369-3fi21 G Manteca 623-7164 0 Tracy 835-6385 Applicant Return all,copies to: Environmental Health PermiV Services 1601 E. Hazelton Ave., P.O. Boa 2009, SW, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK r RECErs'ED By DATE PERMIT NO. r Erl 1124!r1EV.i,mill r1 i'1 � r) n A-b i !/ \�.� :��•-k� ,�,AJC ! ..�