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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELFON AVE., STOCKTON, CA Co <br /> Telephone (209) 466-6781 MPERMIT EXPIRES 1 YEAR FROM DATE ISSUED � �( <br /> (Complete in Triplicate) ++JJ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs 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 /> owners Name Marley Cooling Tower Company Address150 North Sinclair Avenue Phone 465-3431 <br /> Contractor Layne Environmental Address Long Beach, CA License No. 057600469 Phone 213 595-6551 <br /> TYPE OF WELL/PUMP: NEW WELL 919 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 20' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> li Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 13 3/4 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications <br /> 71 Public kl Other n Delta Depth of Grout Seal _100 Type of Grout l�a_t Cement <br /> I I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by Jayne Envirnnmental Services, Inc. _ <br /> Repair Work Done ❑ Type of Pump gIRM H.P. 1/9 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 I REPAIR/ADDITION I 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 a, <br /> Character of soil to a depth of 3 feet: 1r.0 table depth <br /> SEPTIC TANK ❑ Type/Mfg 1rq''�`` Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: V,tl$If� 3 1'Foun Ion Property Line <br /> ' ' COON <br /> SA 70""_5�aTG�"S <br /> LEACHING LINE ❑ No. a Length of lines � h1 StoN Total length/size <br /> FILTER BED ❑ Distance to nearest- pu4"WENTALHE oundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 sub-contracting signature <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 California." <br /> The appficm st call for all required inspections. Complete drawing on reverse side. n /AA <br /> C A Jh /�{'/lQ/��iQ��/� Date: <br /> Signed X -.� Title: �� <br /> OR RTMENT USE ONLY <br /> Application Accepted by Date ( Wee 6!d;�*Pit or Grout Inspection by 04�*Final Inspection by ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8366385 <br /> Applicaqt- 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 CASH RECEIVED BY DATE PERMITNO. <br /> INFO ��%y,�(� <br /> EH 13_N IREV.vxv V � 06) L/� % <br /> EH 1048 <br />