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i 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 Sinclair Avenue, 800' South of Washington Street City Stockton Lot Size PM Owner's Name Marley Cooling Tomer Company Address 150 Horth Sinclair Avenue Phone 465--3451 -Layng Environmental Contractor Services, Inc. Address Long Beach. CA License No.C57600469 Phone TYPE OF WELLIPUMP: NEW WELL LA WELL REPLACEMENT LI DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 18' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 8 519 did Industrial 11Open Bottom ❑ Manteca Dia. of Well Excavation 13 3/4 Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications ! 1`1 Public 1J Other 171 DeltaDepth of Grout Seal lOd' Type of GroutAka .Q�nt-.._-. I I Irrigation ____Approx. Depth ( I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump SUBN. H.P. I/2 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms ft Character of soil to a depth of 3 feet: ft, • Water table depth SEPTIC TANK ❑ Type/Mfg —�,iro13 Capacity No. Compartments PKG. TREATMENT PLT. ❑ vk r� Method of Disposal Distance to nearest: � oun Ion Property Line - INON. LEACHING LINE ❑ No. & Length of lines $A� 1A w aN Total length/size FILTER BED ❑ Distance to nearest FUN�p1LA1-1 aundation Property Line SEEPAGE PITS l I Depth Size Number I SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 Di§trict. 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 California.'.' The a t::,call for all required inspections. Complete drawing on reverse side. Signed X Title:RAA-4632) �4e()4 9��Date: O RTMENT USE ONLY Application Accepted by Dat lea Pit or Grout Inspection by Dateczs/� s Z Final Inspection by Datey Additional Comments: /( ❑ Stk 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 FEE AMOUNT DUE AMOUNT REMITTED OK RECEIVED BY DATE PERMIT'NO. INFO /} ) [ ' +.EH 13-24(REV.I/H5) B qoc EH t4-26 ca - ter•