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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES TYEAR 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 Korner Avenue, 100' lest of Gertrude Avenue City Stockton Lot Size — PM Owner's Name Marley Cooling Tower Com any Address150 North Sinclair Avenue Phone 465-3431 Contractor VZ2 Environmental Address L'6hg. Beach, CA License No. C57600469 Phone(213)595-6551 TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 20' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1J Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 13 314 Dia. of Well Casing 8 5/8 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Steel Specifications M Public $1 Other Ll Delta Depth of Grout Seal -100 Type of Grout Neat Cement I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Layne Environmental Seryire�, Ing. Repair Work Done ❑ Type of Pump .SIIBM. H.P. 1/9 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 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 or Character of soil to a depth of 3 feet: T +s weAl,_w-_I1 I _- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal Distance to nearest: Vk[�EIZ 3 "Found ion Property Line O+yN LEACHING LINE Cl No. & Length of lines SN �t�5 ' Total length/size FILTER BED ❑ Distance to nearest,�V} AL� A oundation Property Line SEEPAGE PITS I ) Depth Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work wilt 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." Thea st call for all required inspections. Complete drawing on reverse side. Signed X Title: �'Jh //1�/�Is - /f Date: OR RTMENT USE ONLY ^/y Application Accepted by 11 Date~ % Be J Pit or Grout Inspection by Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PJERMITNO.\ + EH 1 -241REV.i/n51 OI/ a,-41a,-41V,73— EH 144-28 ! ! /