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• APPLICATION 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 Sinclair Avenue, 800' South of Washington Street city Stockton Lot Size PM <br /> Owner's Name Marlev Coolinq_Tower Company Address 150 North Sinclair Avenue Phone - 451 <br /> �71(7' G[r0/4t' d��CC 202'/ FUA/�T�►/` �/� 1 <br /> Contractot was rn fnmr.aev_ InC. Address License No. J�_�y((//�_Phone 2' - <br /> TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 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 /> ® Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 8 5/8 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public X Other 17 Delta Depth of Grout Seal 86' Type ype of Grout Neat Cement <br /> I I Irrigation —,Approx. Depth 1 I Eastern Surface Seal Insa e 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 v) <br /> Depth Filler Material (Below 501 _ 5 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is (­� <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <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 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I 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 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 sub-contracting signature <br /> certifies the following:"I certify th he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cali rni .' <br /> The applican all f a r u'e i p t m l to drawin n///re a se s 1//�� / �� //M / <br /> Signed X p Title: ^rn V rll YV tt L C.2_7471 <br /> FOR DE TMEN NLV <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by Date Final Inspection b .__ Date�/� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 023-7104 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED ,.yyCASH¢¢ RECEIVED <br /> BBY DATE C /]PERMIT NO. <br /> . EII t}24 IREV.1/951 G�S 1J1�yJ 7/�• 9 Zr L?1_Zyw� <br /> EH I4-26 <br />