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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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 2600 Delano City Stockton Lot Size PM <br /> Owner's Name Patmon Company, Inc. Address 1919 Grand an Blvd..,......Ste, 951-4391 <br /> OC On, - <br /> Contractor Patmon Company, Inc Address Same License ND.r 287583 Phone 951-4391 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYST341 REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L NE5 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL RE 4EELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private .❑ Gravel Pack ❑ Tracy y of Casing Specifications <br /> [7 Public Ll Other ❑ Delta apt of Grout Seal Type of Grout _ <br /> I I Irrigation _.-Approx. Depth t I Eastern Surfac. Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.I <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 IN Type/MfgCapacity 600 Qa 1 s. No. Compartments <br /> PKG..TREATMENT PLT. 1­1C0ver1 ng) Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE El No. & Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L7 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <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 follOWi g: " artify 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 Cali <br /> The appli n or all required inspections. Complete drawing on reverse side. <br /> Signed s Title: President Date: 6/29187 <br /> FOR PARTMENT USE ONLY Q `� t 5 <br /> Application Accepted by �A %I&&nf,t%AAw/1 Date �L� `_% ` Area <br /> f I <br /> Pit or Grout Inspection by Date Final Inspection by F ZZ-A 1 leDate 17. <br /> f <br /> Additional Comments: <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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT•NO. <br /> INFO f�AS/H� !]/� <br /> + EH 13-24 SREV.t/rs 51 �� U L b 24--bl e7-.25/^ <br /> EH 14-28 +r..✓!! `i.V`�'4 !tel / <br />