FIELD DOCUMENTS AND WORK PLANS 1991

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• APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 O ER IT EXPIRES 1 YEAR FROM DATE ISSUED O (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. Job 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 Layne Environmental Contractor Address Lona Beach, CA License No. 057600469 phone (213)595-6551 1.TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1511' SEWER LINES 5nn+ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Bl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 13 3/4 Dia. of Well Casing 8 5/8 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications * Public Rl Other ❑ Delta Depth of Grout Seal 150 Type of Grout Meat Cement I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Layne Environmental Services, Inc. _ Repair Work Done ❑ Type of Pump SUBM. H.P. 1/2 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ( /1 Installation will serve: Residence_ Commercial_ Other �■ Number of living units: Number of bedrooms—IA- Character of soil to a depth of 3 feet: . 12!tuE1D Water table depth Kr SEPTIC TANK ❑ Type/Mfg Z—acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WellAN ,.,, p1ITY• Property Line S .r, V gUSE164EA,L1t,�_' LEACHING LINE ❑ No. & Length of lines —"Y;,lONMENTRL Fi 1 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 ❑ 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 rules and regulations of the San Joaquin Local Health Di%trict. 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 subcontracting signature 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- tion laws of California." The applica t must call for all required inspect ons. Complete drawing on Lkverse side. Signed X Title: [��yl- ��.d��—✓1 nate: r FOR P T SE ONLY Application Accepted by Date �j Area L �� Pit or Grout Inspection by Date Final Inspection by Date 5 L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520- . FEE INFO AMOUNT DUE AMOUNT IT /��A,S,jH,, RECEIVED V L, DATE 9PERMIT NO. }\ S EH 1}N IREV.rix 51 7�9'� ) EH 1624 V 651