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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 Horner Avenue, 100' Nest of Gertrude Avenue City Stockton Lot Size PM <br /> Owner's Name Marley Cooling Tower Canpany Address150 North Sinclair Avenue Phone 465-3431 <br /> Contractor La a Environinental Address Long Beach, CA License No. C576004 one 213 595-6551 <br /> TYPE OF WELL/PUMP: NEW WELL (A WELL REPLACEMENT 0 `D. I ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 20' DISP AL NE <br /> L <br /> FOUNDATION AGRICULTURE WELL OTHE WE PITS/ MPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1J Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation 13 3/4 Dia. of Well Casing 8 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications <br /> 0 Public kl Other n Delta Depth of Grout Seal _100 Type of Grout Meat Cement <br /> I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by I aynP Environmental Servi CPS. Inc. _ <br /> Repair Work Done ❑ Type of Pump SIIRM H.P. 1/9 State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo 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. 0 Method of Disposal <br /> Distance to nearest: Wpl 2 3 1V-oUNdation Property Line <br /> IA.. l'1 <br /> LEACHING LINE 0 No. & Length of lines $A H-01 <br /> (3f. <br /> :. ON_ Total length/size <br /> FILTER BED ❑ Distance to nearest- ?U, ,Q� -HE oundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 appkeen st call for all required inspections. Complete drawing on reverse side. n /AA <br /> C r A ' X !�Y/11/��i4 ,::8 Date: <br /> Signed X Title: �E -� <br /> OR �RTMENT USE ONLY <br /> Application Accepted by --4 Data Area y3� <br /> Pit or Grout Inspection by Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 <br /> Applicagt- 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 AMOUNTTT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> r EH 132/IBEV.I/x el V. L/. 3 <br /> EH 1426 <br />