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• APPLICATION FOR PERMIT 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL REACTS DIVISION [PlyP O BOX 2009, STOCHTON, CA 95201 0 <br /> (209) 468-3447 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby atade•to San Joaquin County for a permit to construct and/or install the work herein described. Title <br /> application Is aside in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 150 N. Sinclair Avenue _ City_5t9cktczm_ Lot Site/Acreage 0± Arrpc <br /> 66202 — <br /> owner's Name Marley Cooling Tower Co_ Address .5800 Foxridge Dr. Miss on" KS Phone(2] I-3b2_181. <br /> 85284 <br /> Contractor Layne Envirolmmental Addres-002 S. Hardy, Telnpe,AZ License No.600469 Phone 00 <br /> TYPE OF WE 5 Tn7•-NEW O WELL REPLACEMENT fl DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR n OTHER & Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._.._ PROP. LINE _ <br /> (See DwR.G-1 & Gfg�NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS (See Section 2A and Dwgs) <br /> Cl Industrial O Open Bottom O Manteca Dia, of Well Excavation _ Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications <br /> IJ Public I:1 Other O Delta Depth of Grout Seal ._ Type of Grout <br /> CI Irngation __.Approx, Depth O Eastern Surface Seel Installed by <br /> Repair Work Done O Type of Pump H.P. Slate Work Done _ <br /> Well Destruction O Well Diameter Sealing Material L Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of $oil to a depth of 3 feel: ._._�Water table depth _ ` <br /> SEPTIC TANK O Type/Mfg Capacity_____ No. Compartments _ <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. 6 Length of lines Total length/sire _ <br /> FILTER BED CI Distance to nearest: Well Foundation ___ Property Line _ <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line _ <br /> DISPOSAL PONDS O <br /> y <br /> rules and regulations of the Sen Joaquin County <br /> I hereby cenifthat I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 compenss <br /> tion laws of California.,, <br /> The applicant must call for all required)Inspectio11ns. Complete drawing on reverse side. <br /> Signed % v �k r ` ' ._- \—t <br /> Titls: . ry L��„_yQcy.� Date: x ll` <br /> .�/ DEPARTb1ENT USE ONLY �// / <br /> Application Accepted by Q 7 Data _/,( g,�� Area <br /> Pit or Grout Inspection by Data Final Inspection by _ Data _ <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERV/CES <br /> 445 N SAN JOAQUIN, P 0 BOK 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECENED aV <br /> INFO �qSH DATE PERMIT NO. <br /> F�1 q lr IAN.11x51 <br /> 'r.M `�6 � bey �,�s/� <br />