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APPLICATION FOR PERM.' ME- Nd� SAN JOAQLiN LOCAL HEALTH DISTRICT 11 CI 1601 ETelephoneN(209) 466-618aN' CA Xt77 PERMIT N0. $S - SAN JOA( vs -T. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED HEATH i31STRiGT (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 12611 E. Peltier R d. Subdivision Name Owner's Name John A. Arishin Address 12611. E. Peltier Rd. Contractor's NameGoehriri P Phone License No. 309031 Phone 727-554 8 Tnc. TYPE OF WELL/PUMP WORK: _ -NEW WELL ❑ . WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial LJ Domestic/Private ❑ Manteca Open Bottom ❑ Dia, of Well Excavation -❑Gravel Trac -- - - Pack _ . _- -Y _ Dia, of Well Casing` ❑ Public ❑ Other [] Del to Ljirrigation Approx. F- Eastern Type of Casing Cathodic Protection Depth =!Specifications ❑Geophysical Dep"th..of Grout Seal r LJ Other Type of Grout w Surface Seal Installed by r Repair Work Done Type of Pump Sub. H.P.�_ 3 !State'Work Done Changed motors Well Destruction ❑ Well Diameter Sealing Material (tg .50') { Depth - / P Filler Materia.l.,(Selo,w,50!.,)..-:" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank oi- seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units: Numbe-r'of bedrooms Character of soil to a depth Wateri._table_depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg �r Capacity Method of Disposal �p Distance DESTRUCTION SEWAGE SYSTEM Ditto nearest: Well Foundation Property Line 1 ❑ LEACHING LINE ❑ No. & Length of lines Total length/size . ] FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj 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 coun ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ty 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 n employ any person in such manner as to become subject to workman§ compensation laws of California," Contractor's hiring or ntracting signature certifies the following: "I certify that in the performance of the work for which this permit is issu I 71 a loy persons subject to workman's compensation laws of California." The applicant must a 1 quired inspections. Complete drawing on'reverse side. Signed X Title: Bk r. Date: 0 2 l 3/8 5 FOR DEPARTMENT USE ONLY Application Accepted by Area p ` ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date L Tracy 835-6385 Applicant.- Return all copies to: �ninmental H lth Permit/Services 1601 E. Ha on Ave., P.O. Box 2009, St k., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. INFO EH 13-24 REV. 10/82 14-26 10/$2 500