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` ✓ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA p AY M ENT Telephone (209) 466-6781 RECEIV50 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N U ��a (Complete in Triplicate) Ju Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work ( aa��pp MaWiiM7, is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules 0 oaquin Local Health District. Job Address & 2025 E. Weber St. City Stockton Lot Size 200' x 1300' PM D. Barber Owner's Name `-rte'chert Lana Cam Address' 103 North "E" St. , Stockton Phone (916) 386-6982 cic �a,, oi� 3814 Auburn Blvd. #62 466258 972-9010 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N Monitor DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES 50' DISPOSAL FLD, none PROP. LINE 10' FOUNDATION 20' AGRICULTURE WELL none OTHER WELL 200'± PITS/SUMPS none INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing 4" ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications F-480 M Public 171 Other ❑ Delta Depth of Grout Seal 40'± Type of Grout Cement bent rite I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by L.B.M.E. Corporation Repair Work Done ❑ Type of Pump submerjblp.p. 1/4 HP State Wo Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below ') ^� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I In D TF UC�TI I 1 (No septic system permitted if public sewer is (,�v /� available within 200 feet.) V Installation will serve: Residence_ Commercial Other JN 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 \11 Distance to nearest: Jell 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 t 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."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 applZAccepte call for all req 'ed inspections. Complete drawing on reverse side. Signed X Title: COLISulting Engineer Date: ^�— i' ah � t 1 OR D ART E USE ONLY - - It Applicatiby Date Area Pit or Grout Inspection by 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO +.EH 1124(REV.tiNs) � EH 14-28