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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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 Distric>c.,�7�3 Job Address 150 N. Sinclair Avenue city Stockton Lot Size' PM Owner's NameMARLEY COOLING TOWER CO. Address 150 Il- Sinclair Avenue Phone-(209)465-3451 Contractor h1YERs BROTHERS Address Hanford, California License W.260310 Phone(209)582-9031 TYPE OF WELL/PUMP: NEW WELL 2 WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 monitor wells PUMP INSTALLATION C 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 O I ii&W Monl tOr ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9-77T Dia. of Well Casing 4° ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal See arawi ngS T pe of GroutNeat Cement ❑ Irrigation 'r '&180' Pressure or pe g �Approx. Depth ED Surface Seal Installed b Y Repair Work Done ❑ Type of Pump SUBM H.P. 1/3-1/2 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septicsystem 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 feet: Water table depth E SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments c 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 SEEPAGE PITS ❑ Depth _Size Number .r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 California." The applicant m t call for r fired inspections. Complete drawing on reverse side. Signed Title: 40 Date: 3/ loz-e- Air SE ONLY r Application Accepted by Date a Pito Grout nspe o Date Final Inspection by Additional Comments: .i�(§tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 F Applicant- Return all copies to: Environmental Health Permit/Serviceq 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + FEE AMOUNT DUE AMOUNT REMITTED CK It INFO RECEIVED BY OATS PERMIT"NQ, s + EH 3-24 EH 14-�IREv.i/e 57 � 1A 5-S' 97-7 l Ik oof _ is G7 ll/X�QB