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APPLICATION FOR PERMIT # SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1YEAR FROM DATE ISSUED NOV 18 1988 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h&WJ8QNE;4+"TW made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and RegP�iMi T�a 10�ii@qaquin Local Health Distiict.' - Job Address 17713 Fntorui¢P...Rd City_C--SCA6VS_ Lot Size 4.82 acres PM Owner's Name Joe Furtado Address 9053 E. Southland. Manteca Phone 524-2504 I Contractor Hennings Bros. Address 3525 Pelandale, Mod. License No. 290813 Phone-545-1185 TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK–A201 -_.- SEWER LINES _.... _.. _ DISPOSAL FLD.100'_ PA6P. LINE 1?(1 t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom M Manteca Dia. of Well Excavation 143' Dia. of Well Casing (N Domestic/Private N Gravel Pack ❑ Tracy Type of Casing PVC Specifications F] Public Cl Other n Delta Depth of Grout Seal 5Q� Type of Grout-Beatonite _ I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by driller _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION t I DLSTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) UP Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 Di§trict. 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." The applicant must call for all required inspections. Complete drawinverse e. Signed x—,HenningS Bros. By Titleon re : �C Date: 11-17-88 off FOR DEPARTMENT USE ON Application Accepted by / f f Date C217 U Area Pit or Grout Inspection by /� DateFinal Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. +.EH EH 14-24 IREV.r i H 57 0 4 Q �a0� ,,/ �'4 s� g