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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA f 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 andlor install the work herein described. This application is I 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. r . 2416 Delano city Stockton Lot Size PM Job Address Owner's Name Patmon COmPa�, Inc. Address 979 Grand tan 1 BIVd. Ste. A- -Phone 951-4391 � 257583 951-4391 Contractor Patmon Company, Inc. Address same License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SY EM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEW LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC LTUR WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications f"1 Public Cl Other ❑ Delta D th of Grout Seal Type of Grout F- + I I Irrigation _.-Approx. Depth I I Eastern Surf Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50.1 Depth Filler Material IBelow 501 J\ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 ! DESTRUCTION availablelwithin 200 feetit'ed if public sewer is +[�� 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 IX Type/Mfg concrete constrUCti Capacity 12�5'Meth Compartments Disposal Z I PKG. TREATMENT PLT. Cl Method of Disposal 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 ❑ Distance to nearest: Well Foundation Property,Line j DISPOSAL PONDS ❑ I hereby certify that I have'prepared this application and that he 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 shallrnot employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring of sub-contracting signature certifies the followin "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 or .' The applic t 'u c r I quired inspections. Complete drawing on reverse side. Signed X { Title: President Date: 6/29/87 O EPARTMENT USE ONLY n ^7l i Application Accep#ed by Date L` xcob Area 1 Pit or Grout Inspection by ft Qat 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, tk., CAy,9520 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. INFO ./� �sl� + EH 13-241REV.I/Ks) � �� 1 EH 14-2e 6 CC....//