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:T f wJu, ,,' _ PEcu(T E,P1RES I YEAR IRIt" :SS'L: .�� .)Vr �'.. �l - - -- > 'Coi^piete in 'r+Ptica:el HEALTH [);STR'('T ADPi+cation is hereby rade to the San JoaGuin Local Health Cistr,CL `or a P.`r-It :0 Con<truct ant'or install the work herein desoribtd. This applicatic• is near '.n c-,"liance with tan :o3,1u�r 'ounty Ordinance No. 5.10 for sewage or No. 1862 for well/purr and the Rules and Regulations of the San Joaquin Local Health "istrict. Job Address J-740 N• HMy• 88 Sub,'.:v.v on 'pare -- - Ow�er , Pumie KEMALYAN & LARSON Addre P.0,Box 7041_, Stockton, Ca_.._ Phone _ Contractor's Name _Goehring Pump License '.o. 309031 _ phone -127.5�A$ , TYPE OF WELL/PUMP W6RK: NEW WELL ❑ WELL REPLACEuENT �_ OESTF}CTION LJ POMP INSTALLA.IDN _ SYSTEM REPAIR OTHER L1 DISTANCE TO NEAREST_: SEPTIC TANx _ _ SEWER LiNES DISPOSAL FLD. _PROP. LINE FOUNDATION AGRiCOIT'JRE WELL DTP[^ W'-LL PITS/S�"PS i ,NTENDEG ;SE— - TYPE 6P itE} :a y �i COMSTRULTT^JN'SPECIFiCAT10NS I�:Indus irtal L1 to" BottdmP' " l.i � �a•;r_{�" '•�l�.of Well Excawtion _ Doarstic/Private 111 Gravel Pack `j Tracy 'iia, of Well Casing L]Public U Other L DeltaI .ype c` �j Irrigation _ t iprox. L7 Eastern ' Specifications FlCathodic Protection N'It h - y Depth of Grout Seal it Geopi+ys i c a l �. Type of Grout J Other _ f. . Surface Seal installed by Repair Mork Done Type of Pump _a% }��H.P. _ 3 State Work Gone relT aced n 1 d tirhi n e Well Destruction U Well Giareter Sealing Material (top 50') Depth _ Filler Mrterial (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATIO'L Lt REPAIR/ADDITION J (No septic tank or seeoage nit permitted if public sewer is available within 200 feet.) Insta`lation will serve: Residence _ Commercial — Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth .iPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity' Method of Disposal _ SEWAGE SYSTEM Distance to nearest: Well Foundation Pr nerty Line 'UCTION LtAtHTNG LiNE U No. 6 Length of lines Total length/kite FILTER BED_ Distance to nearest: Well _ _ Foundation Property Line — SEEPAGE PITS �j ` Depth Size Number - t sL*APS Distance to nearest: Well Foundation _ Property Line =4 DISPOSAL PONOS Q 1 hereby certify that 1 have prepares; this application and that the work will be done in accord,nce 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, 1 sh 1 of employ any person in such manner as to become subject to workmant compensation laws of C.ilifornia." Contractor , hir -contracting signature certifies the following: "1 certify that 'n the performance of the work for which this permit is shal employ persons subject to workman's compensation laws of California." The applicant f 11 required inspections. Complete drawing on reverse side. Signed x_ S _ Title: hl{Qr. --,,._ Date: F DEP TMENT USE 0 v Application Accepted by _ _ Arca _ �L Stk 466-6181 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by _ Date U Manteca 823-1104 Final Inspection D -- -1 i ate �J//�7 Tracy 835-6385 Applicant - Return all c pie to: Environmental Health Permit/Services 1601 E. Hazelton A, P.O. Box 2009, Stk., CA 95201 FEE BASE I AMOUNT DUE AMOUNT REMITTED RECEIVED 61 DATE PERMIT NO. INFO I� �a _ �91�y aA i EH 1?-24 REV. 10132 10/82 500 la-2b L _ �r