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APPLICATION FOR PERMIT lie SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.TON 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. - •.Ca4�0...�. {,.t- -4-v�E��1" "^�` Job Address Cardinal Ave., 1500' South of HWY 26 City Stockton Lot Size .-. . PM Owner's Name Marley Cooling Tower CO. Address 150 N. Si ncl ai r Ave. Phone 465-3451 Contractor Cruse Drilling .-_Address Bakersfield, CR License No278907. Phone (805) TYPE OF WELLIPUMP: NEW WELLS WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONr❑ SYSTEM REPAIR ❑ OTHER 17 9 DISTANCE TO NEAREST: SEPTIC TANK 150 SEWER LINES 500} DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS gl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 8 5/8 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications 17 Public X1 Other F Delta Depth of Grout Seal 15'50 Type of Grout Neat Cement I I Irrigation —.Approx. Depth ' I 1 Eastern Surface Seal Installed by Cruse Drilling Co. Repair Work Done ❑ Type of Pump SEIBM. H.P. 1/2 State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other \\ Number of living units: Number of bedrooms C Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 1 SEEPAGE PITS I 1 Depth Size Number l SUMPS L� Distance to nearest: Well Foundation Property Line i 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."Contractor's hiring or sub-contracting signature certifies the following: "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 Californi ' The applicant mu 11 alt requi ms tions. Complete drawing an reverse side. - Signe X Title: Qe-4111! Date: FOR P SE ONLY �j 3 Application Accepted by7Date r i Q Area q .; Pit or Grout Inspection by Date �✓ �� Final Inspection by Date Z- !� Additional Comments: See MCTC QyXerly Report dated March 2, 1990 and 8 letter from G.Reents ❑ Silk 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, Stk., CA 95201 IFEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BDATE PERMITNO. CK ER +.EH 53-24{qEY.r/H 51 ala-6 h•-��7/J/ /��-^�y EH 1428