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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephorie (209) 466-6781 PERMIT EXPIRES 1'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 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 5375 Van Arlen Road City StocktOTut Size PM Owner's Name Eugene Caffese Address 9000 Ordford Road Phone Contractor Clark Well address_ 202 ' E Charter WaY License No. 371560 Phone -46?--76-7-6— TYPE 6 — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION CR SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL ,OTHER WELL PITS/SUMPS _ INTENDED USE_ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial { ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout — I I Irrigation -Approx. Deth l 1 Eastern Surface Seal Installed by _ Repair Work Done El Type of Pump gub H.P. 3hp - State Work Done _Installed Well Destruction ❑ Well Diameter Sealing Material Stop 501 + Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 n Distance to nearest: Well Foundation Property Line �f' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line W SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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, andf. 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 irt employ any son in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the v owing: "I c ify 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 lif.rni.." The applic m st call f all uired n ti' ns. mplet rawing on reverse side. Signed X Title:SeO—Tres Date: 19 April 1989 FOR DEPARTMENT USE ONLY Application Accepted byi ` Dateq Area Pit or Grout Inspection by Date Final Inspection by date � 4 N % Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /0000 FEEi INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY CK DATE PERMIT'NO. i-EH 13-24 IREV.1/H51 1! EH 14-2e