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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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'Rukes and Regulations of the San Joaquin Local Health District. Job Address 2600 Delano City Stockton Lot Size PM Owner's Name Patmon Company, Tnc._ _ Address 1919 Grand Canal Blvd. , Ste. A-lPhone951-4391 Stockton, CA 95207 Contractor P Address SRmP_ License No.287583 Phone ().91-4,191 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 D Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public I-] Other n Delta Depth of Grout Seal Type of Grout — i I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by i Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction L Well Diameter 8 , casing Sealing Material (top 50') concrete Or cement Depth 65 Ft_ Filler Material (Below 501 pea gravel TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l 1 DESTRUCTION - •'(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 tees: Water table depth SEPTIC TANK "Type/Mfg _ ._ Joundation Capacity� �_,. ; No. CompartmentsPKG. TREATMENT PLT. IJ Method of Disposal Distance to nearest: Well Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wellndation Property Line i SEEPAGE PITS I I Depth Size Number J SUMPS D Distance to nearest: Well Foundation 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!9 such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies thejnt ' 'I' "Irtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws oi The appii all required inspections. Complete drawing on reverse side. Signed Title: Date: .- 6/29187 F DEPARTMENT USE ONLY Application Accepted by .t�►.. .�, �, Q��AA Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: kA f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant 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 INFO AMOUNT DUE AMOUNT REMITTED }CK RECEIVED BY DATE PEERMIT'NO. ♦ EH 13-24 IREV.i?n5S C oZe�) 6 r.7j�,_.4� c�7...�,s EH 14-Z9 W l