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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:TON AVE., STOCKTON, CA Telephone Q09) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r. 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 Allen Road City Stockt OIlot Size PM Owner's Name Eugene Caffese Address 9000 Ordford Road Phone 463-806 Contractor Clark Well Address 2024 E Charter WaY License No. 371 560 Phone AL2=7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION M 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 %I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications IT Public ❑ Other n Delta Depth of Grout Seal Type of Grout_. - r I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump Sub H.P. _3hp State Work Done _Installed Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION I I R[PAIR/ADDITION I ) DESTRUCTION I 1 (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 CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I f 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 SEEPAGE PITS I I Depth Size Number _ SUMPS Ll 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, ander rules and regulations of the San Joaquin Local Health District. which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for employ any ftson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the o owing: "I cartify 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 lifornia." The applic m at call f all ired in tions. mplet cawing on reverse side. Signed — Title:Sec—Tres Date: 1.9 April 1989 FOR DEPARTMENT USE ONLY Application Accepted by f Date - Area Pit or Grout Inspection by Date Final Inspection by Date t.57 51,5,? Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 O Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 1]d/1REV.r/x sl � EH 14M