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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES t YEAR FROM DATE ISSUED (Complete in, Triplicate) Application is hereby made.to San Joaquin County 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 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Joh Address 150 North Sinclair City Stockton Lot Size/Acreage3D + Acres _ Owner's Name Marley Cooling Tower CO. Address 5800 Foxridge Dr' Mission, KS_ Phona 913 362-1818 Contractor I Gyne Env. S lI Address9OD2 Hard�C, TPmnp A7 License No. -,6DDA .9__—Phone -3315 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DES7 RUCTION ❑ Out of Service Well 0 PUMP INSTALLATION [g SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ ti-- '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 For EW-2, EW-3 CA Industdel ❑ Open Bottom ❑ Manteca Die. of Well Excavation Die. of Well Casing be ` (1 Domisdo/Private [g Gravel Pack ❑ Tracy Type of Casing__P1fr Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal 48',145' T Type of Grout Cement-RPntOi 1 to I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by r0 ti ng wl cement-bent2nite & ol Cing Repair Work Done U Type of Pump GrundfoS H.p. State Work Done manhole COVer Well Destruction ❑ Well Diameter 611 Sealing Materiel IS Depth Rpntnni tp 4-5` 2 44' 11' Depth 951t115' Filler Material a Depth Grout 44l /41 ' to clrrface TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo sepeiCwsystem �;tted if public sewer is availablithin 200 Installation will serve: Residence— Commercial— Other Number of living units: — Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No, Companments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well _. Foundation Property Line , LEACHING LINE ❑ No- d Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to neareav Well Foundation Property Lire 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 County Home owner or licensed agent's signature certifies the following: '9 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 workmen's compensation Tawe of California."Contractor's hiring or subcontracting signature certifies the following: "I certify,that in the performance.of the work for which this permit is!@sued, 1 shall employ persons subject to workman's compensa- tion laws of California." Theapplic t cell for ell reg/Ljred (Dipecti AS. Complete drawing on reverse �erse side. (See Figure 1-1 1 Signed x -f' /'i-.J�/ Title. Date: 7- l g1^ FOR DEPARTMENT USE ONLY /� Application Accepted by _ Date r�1 Z7 Z Area 1"'� �� Ii Pit or Grout Inspection by Date Final Inspection by ,EI{l.Ex,r'- Data ? Z I� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �� J Environmental Health Permit/Services (vim 445 N San Joaquin, P 0 Box 2009, Stith, CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED FASB RECEIVED SV GATE PERMIT NO. . FR I}N IREV,riaet Ee u.as