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• APPUCATION FOR PERMIT • <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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address Horner Avenue, 100' West of Gertrude Avenue City Stockton Lot Size PM <br /> Owner's Name Marley Cooling Tower Company Address 150 North Sinclair Avenue Phone 465-3451 <br /> 202Y E, C AM " MOV 37/ -N <br /> Contracto�'�fapBtry>—Fnc. <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Ve� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 150' SEWER LINES 500+ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 91 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 13 1/4 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public kl Other n Delta Depth of Grout Seal��vr,, 88.5' Type of Grout Neat Cement <br /> 1 1 Irrigation _.Approx. Depth I I Eastern Surface Seal Irstaildy Western Company, Inc. _ <br /> Repair Work Done ❑ Type of Pump SUBM. H.P. 1/2 State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION ( I (No septic system permitted if public sewer is <br /> available within 200 feet.) S <br /> Installation will serve: Residence_ Commercial_ Other h <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal 4-1 <br /> Distance to nearest: Well Foundation Property Line <br /> I.(=ACHING LINE ❑ No. & Length of lines Total length/size <br /> FI TER BED ❑ Distance to nearest: Well Foundation Property Line <br /> P <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 Di3trict. <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 sub-contracting signature <br /> certifies the following: "I certify t 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 California." //�� AAA <br /> The applican call f r r q it i i Ls/Complete drawing qn►fse sj/Ye�A /� // <br /> Signed UU Title: L/ G/��VII/ {//� Date: <br /> �.1? ENT USE ONLY <br /> Application Accepted by / Date <br /> Pit or Grout Inspection by Date Final Inspection by Date/ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EHI3-I8IREY.rix s� ty yS O� � L 9Q-S ��'/ �/•�y7'9 <br /> EH tt-2a ---"`��' <br />