FIELD DOCUMENTS AND WORK PLANS 1991

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• APPLICATION FOR PERMIT 0 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address Walker Lane,1100' South of Main Street City - Stockton Lot Size PM Owner's Name Marley Cooling Tower Company Address 150 North Sinclair Avenue Phone 465-3451 I coLAPIC Nlsu►Z'f G 242gAF. CA44eYeP c Phon2- Contraoi3� w TYPE OF WELL/PUMP: NEW WELL 99 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150 SEWER LINES 500+ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ® Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 13 3/4 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications 1-1 Public 91 Other ❑ Delta Depth of Grout Seat 138 Type of Grout Neat Cement I I Irrigation —.Approx. Depth I I Eastern Surface Seal Insta"Iled bye WBStern COmOany. IRC- _ Repair Work Done ❑ Type of Pump SUBM. H.P. 1/2 State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 —_ O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 75— available available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 t` PKG. TREATMENT PLT.❑ Method of Disposal n Distance to nearest: Well Foundation Property Line 3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ 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 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." Contractor's hiring or sub-contracting signature certifies the following: "I certify t,"the performance of the work for which this permit is issued,I shall employ persons subject to workman's comperi tion laws of Ca,iforn' .' The applican call f r it i triplets drawing ory0=raeyQe/S /LN6Al fl Sign ed X Title:_ GW Date: FO E RT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE [ INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED 9Y Q DATE PERM17:N0EH . • ;4-203 EH 424(REV.rr x s)