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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 'i 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 far sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. l �4 JU cr`f A444ta1 CISL4 . Job Address —.1${)-_IrlO �a�Cw.AVenue City Stockton Lot Size PM Owner's Name Mar 1 ey Coo 1 i ng Tower CO. Address 150 North S i nc 1 a i r Avenue Phone 2097465-3451 7803 Shofner Lane Contractor Rival Waterwel 1 Address Bakersfield, CA 93308 License No. 501337 Phone 8057399-891 TYPE OF WELL/PUMP: NEW WELLXX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONXX EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS XD(RSiiAa3fFmon I tOr El Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing 411 ❑ Domestic/Private XXGravel Pack ❑ Tracy Type of Casing PUC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout S6al see d raw i n eat cement ❑ Irrigation 80 & 1B02Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 'L]l Type of Pump su bm H.P. 1/3 — 1/2 State rk Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic a� syste r �I biic sewer is RVtkt� e Installation will serve: Residence_ Commercial_ Other FERMIY/SERVICES. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 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 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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."Contractors 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 Califia." The applicantst r al }red inspections. Complete drawing on rgverse s 516. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �U Area Pit or Grout Inspection b L Date Final Inspection by Date i - Additional Comrinents: d ddwC \ ❑ Stk 466-6781 ❑ Lodi 3M-3621 ❑ Manteca 823-7104 ❑ Tracf 835-M 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 CK RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.1/55) as, LID �O-S• Cn DDS/6) EH 1428