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n 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local health District. Job Address 2516 Delano City Stnrktnn Lot Size PM Owner's Name Patmon Come, Inc. Address 1919 Grand canal R'ltrri Ste -,ANIDne 951-4391 Stockton, CA 95207 Contractor Patf3on Company, Inc-Address Sallie License No. 287583 Phone 951-4391 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 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 M Public F1 Other 71 Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H-P. State Work Done _ Well Destruction IR Well Diameter _ Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.I 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundatio Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Xndation Property Line SEEPAGE PITS I I Depth Size Number SUMPS C1 Distance to nearest: Well Foundatio 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 certifiesXfollow' ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawThe appll required inspections. Complete drawing on reverse side. SignedTitle: President Dace: 6/29/87 FDR.DEPARTMENT USE ONLY Application Accepted by -OA Date Area 15 Pit or Grout Inspection by Date Final Inspection byd „_,- Date 7 c Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNNT/T DUE AMOUNT REMITTED K RECEIVED BY DATE ryryry PERMIT' 0. + EH 13-24(REV.r i n 5) EH 14-26 LLLJJJJ v I