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iN r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 2516 Delano City Stockton Lot Size PM <br /> Owner's Name Patmon Company, Inc. Address 1919 Grand Canal Blvd- , Ste_ A–thone 95 -41QI <br /> Contractor Patmon Company, I nC. Address same License No, 287583 Phone 951-4391 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public f f Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. I State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material [top 50'1 <br /> Depth Filler Material iBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i I DESTRUCTION IA (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK EX Type/Mfg h I ng k rQnstruc ti nil Capacity3Q09aIS • No. Compartments <br /> PKG. TREATMENT PLT. ❑ kwood COVe Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:g g g: "I certify that in the performance of the work for which this permit is issued, I shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the folio ng: " certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of I' r <br /> The applic t I aft required inspections. Complete drawing on reverse side. <br /> SignedX Title: President6/29/87 <br /> Date: <br /> F OEJZARTfiAENT USE ONLY nn <br /> Application Accepted by �Q Xwyciiii.0A �o Date "1 Area <br /> Pit or Grout Inspection by Date Final Ins ction by Date / l <br /> Additional Comments: _ �� _ 7 r� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUEE� AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> + EH 53-24 IREV,t i n sl (/1� <br /> EH 14-26 <br />