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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ \ 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (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 lot sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. San Joaquin r. Job Address5475 S. Van Allen Road city County Lot Size PM Owner's Name Eugene Caffese Address 9000 Orford Rd. . Stkn Phone 463-8067 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE U 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other fl Delta Depth of Grout Seal Type of Grout_ e I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction IN Well Diameter Sealing Material (top 501 Depth 43 a Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION I I nfPAI P./ADDITION I I DESTRUCTION 1 I (Noseptic 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal �. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 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 I 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."Contractors 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 applica must call for all re fired inspections. Complete drawing on reverse side. /_ Y Signe — Title: 4, JA Date: :7 CQ 4 r4 FOR DEPARTMENT USE ONLY Application Accepted by _ _ Date 2 Area Pit or Grout Inspection Date Final Inspection by Date 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, Silk., CA 95201 r FEE I AMOUNT DUE AMOUNT REMITTED CK II RECEIVED BY DATEZe PERMIT*NO. INFO [� /I •. TXSH EH 1}N IREV.rrx51 �C •'�� .� V 7J Z_ 'L r7` h– - DI 14-m s�J •./ III�"