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" APPLICATION FOR PERMIT A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 150 N. Sinclair Avenue Stockton <br /> City Lot Size PM <br /> Owner's Name MARLEY COOLING TOMER CO.Addraas 150 N. Sinclair AVE. (209) 465-3451 <br /> Bakersfie 30 Phone <br /> Contractor RIVAL NATER WELL Address 7803 Shofner Lane 501337 (805)589-92 <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION [ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> xl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10H <br /> ❑ Domestic/Private Dia. of Well Casing <br /> I�Gravel Pack ❑ Tracy Type of Casing I i cap Steel <br /> Cl Public ❑ Other Specifications <br /> r ❑ Delta Depth of Grout Seal See Drawing Type of Grout Neat Cement <br /> ❑ Irrigation 18�pprox. Depth ❑ Eastern Surface Seal Installed by Pressure or 1remie <br /> Repair Work Done ❑ Type of Pump SUBM H.P. O State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') ..� <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR,ADD, ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) V <br /> Number of living units:_ Number of bedrooms <br /> Character of soil to a depth of 3 feet:. <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size t�, <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number ^� <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature t <br /> 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- <br /> tion laws of Cali rnia." <br /> The applicant st all r wired inspections. Complete drawing on r verse ss a. <br /> Signed Title: /Y7C/�4r✓ Date: <br /> FW DEPARTMENT USE ONLY // �) Q `� <br /> Application Accepted by � Date b"— 6— V / ;Z <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 4666781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED x <br /> INFO RECEIVED BY DATE PERMIT"NO. <br /> + EH W28(REV.V 0 sl /®[-s B /�/ I <br />