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- •.waw _..- ....—e.v.r • APPLICATION FOR PERMIT 1 l 1 SAN E. HATE LOCAL HEALS DISTRICT C 1641 E. HAZELrON AVE., STDCK70N, CA PERh1IT N0. Telephone (209) 466-6781 . DATE IssuED a1 a�-� PERMIT EXPIRES I YEAR FROM DATE ISSUED (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 Ordinarce No. 549 for sewage or No. 1862 for well/pump and the Rules and.Regulations of the San Joaquin Local Health District. Job Address 4747 Bond Rd. Subdivision Name Owner's Name ,john Ferraiolo Address Phone 931-5720 Contractor's Name Valley Mechanical Inc License No. Phone.�oz,_nn�i TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Lf PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE f .i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA t CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca D4a. of Well Excavation # k ❑ Domestic/Private ❑Gravel Pack Lf Tracy Dia. of Well Casing. --� Public Other Delta ❑ ❑ ❑ Type of Casing L- Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout seal k 16. ❑Geophysical Type of Grout ❑Other Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction [f Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION a (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation willpserve: Residence X Commercial Other k Number of living units: 1 Number of bedrooms 4\ Lot size Character of soil to a depth of 3 feet: jWater table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ' LEACHING LINE „Lf No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line r l SEEPAGE PITS ❑ Depth Size Number ' If SUMPS U Distance to nearest: Well Foundation 35o Property Line DISPOSAL PONDS- ! ❑ Add 2' x 14' x 100' Lona Sum I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county j 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 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 fallowing: "I certify that in the performance of the work for which this permit i i ued, I shat empl persons subject to workman's compensation laws of California." F The appl ' ant m call or r 1 u ed inspections. Complete drawing on reverse side. r _ Signed Title: Estimator Date: 10/27/83_ OR A ENT U�E ONLY r �tk 466-6781 Application;Accepted by w.a-- Area _L r Lodi 369-3621 Additional Comments: Pit or Grout Inspection _V t Date — 3 ? ' LJ Manteca 823-7104 Final inspection by Date3 k ❑ Tracy 835-6385 3 Applicant - Return•all copies to: Environmental Health Permit/Services 1 01'E. Hazelton Ave., P.D. Box 2009, Stk., CA 9520I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 14/82 500 EH 13-24 REV. 10/82 3 Y ! 14-26 { '