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APPLICATION FOR PERMIT • SAN 16001J E. HAZENIONCAVE.,EA AVE., RECEIVED Telephone (209) 466-6781 FEB 2 8 1995 PERMIT EXPIRES 1 YEAR FROM DATE ISSUES IVIRONMENTAL HEALTH (Complete in Triplicate) Pt and/or ins woIRM � NI talithe cation is madle int complliance with SanoJoaqu nthe San County OrdinaJoaquin lnce Nto.549 for sewage or h District for a permit 1862 for cwell/pump and the Rules and Regulations of the San ppll Joaquin Local Health District. q04 W clha F W _ City St k-tQZ Lot Size PM Job Address � Leo and Eva Volpi Address P.O. Box 58 Phone 464-67(ej 1P Owner's Name '��/,+,rs�( Contractor mr >m•- L�- nv Address y425 / qn'�1"' License No. Phone TYPE OF WELL/PUMP: .,., NEW WELL Q 4 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Soil boring (13) DISTANCE TO NEAREST: SEPTIC TANK 30 feet SEWER LINES N/A DISPOSAL FLQ. N/A PROP. LINE Meet FOUNDATION 10 feet AGRICULTURE WELL N/A OTHER WEU 3 4 PITS/SUMPS N/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R inrhpc Dia. of Well Casing 4_i,n_-. Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing sch 40 DVC Specifications FI Public P-q Other Pq Delta Depth of Grout Seal 16 feet b4s Type of Grout 3Oftgroutry Benton t A , E - --- tur i i Irrigation pp ox. Depth I I Eastern Surface Seel Installed by� Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter 4 inches Sealing Material (top 50') Depth 30 feet Filler Material (Below 50') 7depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAJOADOITION I I DESTRUCTION i I (No septic syublic sewer is v available with Installation will serve: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water tSEPTIC TANK ❑ Type/Mfg Capacity No. CoPKG. TREATMENT PLT. ❑ Method 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 r SEEPAGE PITS I I Depth Size Number a SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - I hereby certify that 1 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 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 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 mustcall for all required inspections. Complete drawing on reverse side. Signed X s / Title: ��-�� (+�/� Date: g'r FOR DEPARTMENT USE ONLY Date Ar� " Application Accepted by Pit or Grout Inspection by .ZZ qS Date Final Inspection by Date fc /� Additional Comments: ::�iieS.0 ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box S • C 2Q O FEE CK RECEIVED 9Y DATE PERMI NO. AMOUNT DUE AMOUNT REMITTED CASH NFO ♦ EH 13-24IREV.1/x5) �7a />/i�. 17 gs Db5 �g EH 1425 Vill /