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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address r{ia'l:ke-��rnrLane 1100` South of Main Street City Stockton Lot Size PM r Owner's Name Marley Cooling Tower Comyany Address 150 Horth Sinclair AvenuePhone- 465-3451 Contractor Layne Environmental Address Long Beach,,CA License No. C57600469 Phone (213)595-6551 TYPE OF WELL/PUMP: NEW WELL Lf9 WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1501 SEWER LINES 500+ DISPOSAL FLD. POOP. LINE p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E KI-Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 13 3/4 Dia. of Well Casing 8 5/8 I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications ]j FI Public X1 Other C] Delta Depth of Grout Seal 150 Type of Grout Neat Cement_ 1 I i Irrigation ..Approx. Depth I I Eastern Surface Seal installed by Layne Environmental Services, Inc. Repair Work Done ❑ Type of Pump SUBM. H.P. 1Z2 State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material [Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION 1 I DESTRUCTION i I (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_AV 141 Character of soil to a depth of 3 feet: ", I--C Water table depth SEPTIC TANK ❑ Type/Mfg C city No. Compartments PKG. TREATMENT PLT. ❑ �R 2W Method of Disposal Distance to nearest: Well U1 Property Line LEACHING LINE ❑ No. & Length of lines k,�}}l(�Nt�iEl�lit�-t' ' Total length/size FILTER BED' ❑ Distance to nearest: Well Foundation Property Line I` SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll 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 Di$trict. 1 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 applica t must call for all required inspect' ns. Complete drawing on r verse side. Signed X Title: ate: FQR P T 5E ONLY J� . Application Accepted by Date `/ Area Pit or Grout Inspection by Date � r?' Final Inspection by Date S 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 95201FEE y INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED Y DATE PERMIT NO. +. EH 14.28 EH 13-24(REV.1/8 51 LLLLJJJ! `' 11 l