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J APPLICATION FOR PSRYIT <br /> �I <br /> l SANQJAQUIN COUNTY PUBLIC IIEALTOERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> _PERMIT EXPIRES 1 YEAR FROM DATE TS 1Fn <br /> (Complete in Triplicate) <br /> Application is hereby made to Baa Joaquin County for s permit to construct and/or install the work berein described. This <br /> application is wade in ccoo liance with Sam Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of Ban <br /> Joaquin County Public Health Services. <br /> Job Address _ 150 N. Sinclair Ave. (Figure 1) City Stockton Lot Site/Acreage <br /> Owner's Name Marley Cooling Tower Co. Address 150 N. Sinclair Ave. Phone(209) 465-3451 <br /> Rival Water P.O. Box 80537 <br /> Contractor Well Drilling Address Bakersfield, CA 93380 License NoC-57501337 Phone(805)399-891 <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT 11 DESTRUCTION Ll Out of 9ervlce Well <br /> ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Monitoring Well Qy <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-Please see Figure 2 <br /> A Industrial ❑ Open Bottom ❑ Manteca Drs. of Well Excavation 13 Dia. of Well Casing 65/ <br /> (.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Steel <br /> Specifications <br /> I'I Public K) Olhar fl Delta Depth of Grout Seal 150 Type of Grout <br /> I I trfignion _Approx. Depth I I Eaaurn Surface Seal Insulted by 2ival Water Well <br /> Repair Work Done 0 Type of Pump Submersible H P '� State Work Done _ <br /> Well Desmrction ❑ Wall Dismeter Sealing Material L Depth <br /> Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I [No septic system permitted it public sewer is <br /> available within 200 lest.) <br /> Installation will serve Residence _ Commercial_ Other <br /> Number of living units: _ Number or bedrooms <br /> Character of Serif to a depth of 3 fiat: 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 D No, A Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS - LI 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 County <br /> Home owner or licensed agent's Signature cenifiss the following: "I comity that in The perlormence 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 comity that in the performance of the work for which this permit is issued, I $hall employ persons subject to workman's cornpenss <br /> lion haws of California.- <br /> The applicant It ca r all r Wired Inspections. Complete drawing on reverse side. <br /> Signed Title: 6444(1/ Date: <br /> �y <br /> FOR DEPARTMENT USE ONLY 0/ <br /> Application Accepted by Date { llbL /C U1[,w�C(( <br /> Ares <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> AdditonalCommenta: MW-446 (Proposed Well Identifier) <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P.O Dox 2009, Stkn, GA 95201 <br /> FEE <br /> INFO O AMOUNT DUE AMOVNT REMITTED C RECEIVED BY ATf PERMIT'NO. <br /> ] fCA\SH J ,{ <br /> - <br /> EH <br />