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,+ r APPLICATION FOR PERMIT VAN JOAQUIN LOCAL HEALTH DISTRIe. NT 1601 E. HAZE T ON AVE., STOCKTON, CA p AY Telephone (209) 466-6781 R E G E MI V ED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3 U 1988 (Complete in Triplicate) JUN �f" Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work MW�(,aurpp&1V is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules�WTTaSJOIEloaquin Local Health District. ff Job Address & 2025 E. Weber St. City Stockton Lot Size 200' x 1300' PM D. Barber Owner's Name 'N=itlert lean CCEPany Address* 103 North IT!' St., Stockton Phone (916) 386-6982 Contractor L.B.M.E. Corporation Address 3814 Auburn Blvd., #62 License No. 466258 Phone 972-9010 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10411 Dia. of Well Casing 411 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications F-480 Fl Public n Other n Delta Depth of Grout Seal —40'+— Type of Grout cement nt nit I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by L.B.M.E. Corporation _ Repair Work Done ❑ Type of Pump submerjb1q.p. 1/4 HP State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Ira available within 200 feet.) Installation will serve: Residence_ Commercial_ Other D 1�I1 n C� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �iCJ}8 e SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line PL-NI�„I I J 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 ❑ 1 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, 1 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 appIi ant mob call for all req 'ed inspections. Complete drawing on reverse side. �( Signed KI Title: Consulting Engineer Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by'' Date Final Inspection by Date Additionel Comments: O 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 CK RECEIVED BY DATE PERMIT*NO. INFO CASH ♦ EN 13-24(REV.tax 5) EM 14-2e